IPA Matching Form

You will hear from us within 24 hours of completing this form!

Clinic tel. 613-688-3230
info@ivanovapsychology.com

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/email from our clinic with next steps in receiving services within 24 hours. 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.

**DRS. IVANOVA & WIROVE ARE NOT ACCEPTING NEW PSYCHOTHERAPY CLIENTS. ASSESSMENTS ONLY.**

Full Name

First and Last Name

Date of Birth

Age

How did you hear about us?

if website, specify: Psychology Today, Google search, friend/family, etc..

Write NAME of Friend, Family member, Colleague, Doctor who referred you OR Website you found us on:

if using website, help us know better what search terms you used. If its a friend/family/colleague, to provide best care, we want to avoid assigning same clinician as your loved ones

Email address

Primary Phone Number

Address

Street name number, City, Postal Code

If this is an insurance related claim, provide your claim # (WSIB, VAC K#, etc.)

Provide your CLAIM NUMBER

If this is WSIB claim, please provide your Case Manager name and contact

Name and Contact of Case Manager

If using an insurance company, provide name of your provider and details of your insurance plan

Does your insurance cover?

Registered Psychologist

(WAIT LIST ONLY)

Registered Psychotherapist

Psychologist in Supervised Practice, being supervised by a registered psychologist

If you see someone being supervised by a psychologist (e.g., Psychologist in Supervised Practice), you would be the client of the registered psychologist, and the name and license number of that psychologist would appear on all invoices/receipts for the insurance provider.

Registered Psychotherapist (Qualifying), Supervised by a Psychotherapist

If you see someone being supervised by a psychotherapist (e.g., RP(Q)), you would be the client of the psychotherapist, and the name and license number of that psychotherapist would appear on all invoices/receipts for the insurance provider.

Practicum Student (RPQ) $120

supervised by a Registered Psychotherapist

Unsure

Please look into your insurance policy for eligible coverage

What services are you seeking with us?

Psychotherapy Psychological Assessment Diagnostic Assessment AND Psychotherapy ADHD Assessment Unsure Other

FOR ASSESSMENTS ONLY: would you like us to fax a copy of the final report to your Family Physician?

Yes No Unsure

To be discussed with your psychologist

What are the PRIMARY issue(s) you are contacting us about/would like our help with?

List any major life stressors in the past year; or any significant life changes

Are there cultural concerns you'd like us to be aware of?

E.g., cultural, racial, gender, sexual orientation, ability levels, etc.

What is your preference for services?

In Person Virtual Hybrid: In Person & Virtual Either in Person or Hybrid, whichever is available sooner Phone

Do you have a preference for an associate at IPA?

specify name of the clinician you are interested in working with, or leave blank if open to best fit.

Sex at birth

Gender

Sexual Orientation

Have you received Psychotherapy or Psychological Services in the past?

Yes

Yes, when and for how long? No, this is my first time

Describe past treatment

When? for how long? Seen by whom?

Are you having any difficulties with sleep?

Sleep too little

Sleep too much

Trouble falling asleep

Trouble staying alseep

Disturbing dreams

No sleep problems

Do you regularly use alcohol?

Yes No

In a typical month, how often do you have 4 or more drinks in a 24-hour period?

Daily

Weekly

Monthly

Rarely

Never

Have you ever had thoughts of taking your own life?

Have you ever attempted suicide?

Have you tried to take your own life?

Have you had suicidal thoughts recently?

Please describe if they were passive or more intense and persistent

Do you engage in self-harm behaviours?

Have you ever needed to be hospitalized for mental health or addiction issues?

If yes, describe the presenting issue and how long you were hospitalized?

Have you ever needed to be off work for psychological/stress-related reasons?

Are you currently in a relationship?

Yes No

How long have you been in this relationship?

If not, when was your most recent significant relationship?

What is your marital status?

Single

Married

Partnered

Common-Law

Separated

Widowed

Never Married

On a scale of 1-10 (10 being the highest quality), how would you rate the quality of your current relationship?

Do you have any children?

if yes, what are their ages?

Who do you go to for social support? (if applicable)

Are you currently employed?

Yes

Student

If Yes, who is your current employer?

What is your Job Title?

Please list any work-related stressors, if any?

May we leave a voice message?

Yes No

May we contact you by email? (even with encrypted email services we use, there is a possibility of interception despite using more secure email service, e.g., Hushmail)

Yes, I consent No

To provide best match, do you give consent to share your name, email address and any other information you have provided us with one of the clinicians on our team once fit has been discussed with you?

Yes, I consent

No, I would like to speak to the clinic staff first

Let us know any other comments you feel are important for us to know

Your information will be encrypted.