Veteran Pain Program

Contact Us

Other ways to get in touch

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

If you are interested in participating in our Pain Program for Veterans of the Canadian Armed Forces, please fill out the following form.

If you are a referring provider, please complete the veteran's information below.

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 our Veteran Pain Program clinicians 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

Name of referrer:

e.g. Name of physician, hospital program, mental health provider, or case manager.

Case Management

Please provide your VAC K Number (K#)

Please provide your VAC case manager's name

If you don't have one, please input "None"

Please provide your VAC case manager's phone number

If you don't have one, please input "None"

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.

Please add your diagnoses that were not on the list:

Are you concerned about either of the following issues:

Self harm

(deliberately hurting your body)

Suicidal thoughts

Neither

Services

Which service are you interested in: Please note that we DO NOT provide Psychoeducational Assessments.

Psychological Assessment PRT (Pain Reprocessing Therapy) Group Psychotherapy (Individual)

Please tell us a little about the services you are seeking.

Are you seeing in-person or virtual services?

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.

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 your pain symptoms that you want to address and any issues that you see as being related to your pain. 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: Choose all that apply.

Weekday Mornings

Weekday Afternoons

Weekday Evenings

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.