Psychological Services Inquiry

Thank you for contacting Connected Hands. We are located at 320 Ferndale Avenue, Unit #5, London, ON, N6C 5P7.

To inquire about services, please complete and submit the form below and you will be contacted as soon as possible for a free initial 15-minute phone consultation to determine whether our services would meet your needs/goals. Please note this is a secure web form.

Connected Hands generally operates during regular business hours and does not provide emergency or crisis support. In the event of an emergency or crisis such as significant risk of serious bodily harm to self or others and/or other personal and psychiatric emergencies, please go to the emergency department of your nearby hospital, for those under 16 contact Tandem at 519-433-0334, for those 16+ contact Support Line at 519-601-8055 or toll free at 1-844-360-8055 or, if the situation warrants, call 911.

First name

Last name

Phone number

May we leave a voicemail?

Yes No

Email address

Preferred method of contact

Phone

This service inquiry is for

Myself Someone else

Age of person for which services are being sought. If this service inquiry is for someone else, please include their name here.

If you are making an inquiry on behalf of a child, are you the legal guardian?

Yes No

Services being sought

Assessment

Treatment

Consultation

Briefly, indicate reason for seeking services

I consent to this information being collected by and further contact from Connected Hands: Centre for Psychological Wellbeing

Your information will be encrypted.