IPA Onboarding + Matching Form

Please correct the errors described below.

Let us help you get connected with the best possible therapist match. We will use this encrypted and CONFIDENTIAL online form to help provide personalized recommendations.

After you submit this form, you will receive a follow up call from our clinic with next steps in receiving services within 1-3 business days. If we can not assist you, we will do our best to refer you to the appropriate professional.

This form is reviewed by intake coordinator and clinical directors. If you prefer to contact our office before completing this form, please call our clinic 613-688-3230 and we can set up a phone intake with our intake coordinator/administrator.


First and Last Name
if website, specify: Psychology Today, Google search, friend/family, etc..
Street name number, City, Postal Code
Provide your CLAIM NUMBER
Name and Contact of Case Manager
When? for how long? Seen by whom?
Name of drug, dosage, purpose
Have you tried to take your own life?
Please describe if they were passive or more intense and persistent
if yes, what are their ages?
specify name of the clinician you are interested in working with, or leave blank if open to best fit.

Your information will be encrypted.