Dynamic Psychotherapy & Psychology Centre

Contact Us

Other ways to get in touch

Phone: 613-817-8538
Email: info@dynamictherapy.ca
Website: www.dynamictherapy.ca

To help us help you as quickly as possible, please fill out the following form.

Your answers to these questions will help us connect you with a clinician that best matches your needs.

The form is encrypted, secure, and provided through a company that follows Canadian privacy laws.

When you submit the form, please be aware that our receptionist, clinic directors, and the therapist you choose to work with will have access to this information to facilitate treatment.

About You

First Name

Last Name

Age

Please keep in mind we work only with adults 18 years of age and older.

Date of Birth

Identified Sex or Gender

Contact Information

Email address

Phone Number

Please do not include dashes/hyphens

Can we leave a voicemail at the phone number you provided?

Yes No

City

Referral information

Who referred you to us?

e.g. Psychology Today, name of physician or hospital program, name of mental health provider

Case Management

Are you case managed or a member of any of the following groups? Please leave this question blank if it does not apply to you.

VAC

or spouse or dependent of a veteran

WSIB

CAF

Please provide your VAC K Number (K#)

If you are case managed, please provider your case manager's name and phone number:

Please provide your WSIB claim number:

Please provide your case manager's name and phone number:

CAF Member Number (M#)

Insurance

It is wise to check with your insurance provider to know what types of services and professionals they cover. If you know what professionals your insurance covers, please tell us below so we can set you up with the best fit.

Select which professionals you know are covered under your insurance plan. If you are not sure, please call your insurance provider or check your plan. If you do not have insurance, then move on to the next question.

Registered Psychologist (C.Psych) - Waitlist

Licensed with the College of Psychologists of Ontario

Registered Psychotherapist (RP) - Immediate Availability or Short Wait

Licensed with the College of Registered Psychotherapists of Ontario

Registered Psychotherapist (Qualifying) - Under Supervision - Immediate Availability

Under supervision of either a Registered Psychologist or Registered Psychotherapist (our receptionist will follow up with you)

Doctoral or Masters Student - Under Supervision of a Psychologist - Immediate Availability

Under supervision of a Registered Psychologist

Diagnoses

We ask about specific diagnoses from doctors, psychologists, and psychiatrists to that we can make the best recommendations for therapists based on your situation.

Have you been given any of the following diagnoses by a regulated healthcare provider? Do not include diagnoses that have not been told to you by a healthcare provider.

Alcohol or Substance Use Disorder

Bipolar Disorder

Borderline Personality Disorder

Eating Disorder

Functional Neurological Disorders (FND)

Post-Traumatic Stress Disorder

Trauma

Treatment Resistant Depression

Psychosis

Are you concerned about either of the following issues:

Self harm

(deliberately hurting your body)

Suicidal thoughts

Neither

Services

Please let us know how we can help you: Please note that we DO NOT provide Psychoeducational Assessments.

Psychotherapy (Individual) Couples Therapy Psychotherapy Training or Consultation

We provide training and consultation for mental health practitioners.

What is your highest level of education?

Please tell us a little about what you hope to learn?

How do you want to meet with your therapist?

In Person

At our office in Kingston, Ontario

Virtual

Through our secure online videoconferencing program

In Person or Virtual

If you want to meet online, please be sure that you have a private place to meet for sessions where you will not be disturbed or overheard, and that you have appropriate technology to run Zoom for video calls.

Do you have a preference for a particular gender of therapist?

Male Female Either

Specific Difficulties

Legal Issues Are you contacting us in relation to any legal problems, child custody, or legal civil action?

No Yes

We do not have the specialized expertise to best work with people involved in court processes or child custody cases but we can recommend experts who can help with legal cases.

We recommend that you reach out to the following therapists for more information:

Motor Vehicle Accident Claims Are you contacting us in relation to a Motor Vehicle Accident or HCAI claim?

No Yes

We do not have the specialized expertise to best work with people involved in the Motor Vehicle Accident claim process but we can suggest other providers who provide this specialty service.

We recommend that you reach out to the following therapists for more information:

If this situation applies to you, would you like our receptionist to call you for more information, or are you happy with our recommendation to see other providers?

Please call me.

Select this option if you want to discuss your situation in more detail with our receptionist.

Do not call me.

Select this option if you will try another clinic and do not need further contact with us.

The Issues

Please give us a short description of the types of issues you want to address. Keep in mind our receptionist and clinic directors will see this information.

Availability

In general, our clinicians are available during weekday hours from 9 am to 5 pm, though there is some flexibility for after-hours or weekend appointments.

Please tell us your availability so we connect you with the most appropriate therapist. Choose all that apply.

Weekday Mornings

Weekday Afternoons

Weekday Evenings

Weekends

If your schedule is limited, please let us know a little more about when you are free for sessions:

Free Consultation Call

Our therapists offer free 15 minute consultation calls to make sure that there is a good fit between client and therapist.

If you would like a free consultation call, please type the name of therapist you would like to speak with.

If you are unsure, write "Any" and we will have the most appropriate therapist with the shortest wait time give you a call.

Next Steps

Thank you for filling out this form. Sharing your information ahead of time is the easiest and quickest way for us to set you up and move toward meeting your goals.

To get started as quickly as possible, are you willing to let us share your information (everything written in this form) with an appropriate therapist in our clinic either for the consultation call or to book you for an appointment?

Yes, I would like a CONSULTATION CALL

Our receptionist will email you some dates and times and available therapists to get the process started.

Yes, I would like to BOOK MY FIRST APPOINTMENT

Our receptionist will email you some dates and times and available therapists to get the process started.

No, have the receptionist call me for more details first.

Our receptionist will call you within 3 business days to discuss how to move forward.

Your information will be encrypted.