Intake form

Please note: We are unable to offer crisis services. If this is an emergency, please call 911, proceed to your nearest emergency room, or call your local mental health crisis line. A Canada-wide number is available at 1(833) 456-4566; for more information, visit crisisservicescanada.ca.

Please note that by submitting this intake form you are consenting to being contacted through the email address you have provided. Please specify if you would prefer to be contacted by phone.

What service are you interested in? Please note that all of our services are for adults (18+), and we do not offer child or adolescent services.

Individual Therapy

Relationship/Couple's Therapy

Sex Therapy (individual)

Sex Therapy (couple)

ADHD Assessment

Would you prefer virtual sessions, in-office sessions, or the option of both?

Virtual

In-office

Option of both

No preference

What is your first name?

What is your last name?

What is/are your gender identity and pronouns?

e.g. female, she/her/hers

What is your partner's full name?

Please include your partner's pronouns; if you have more than one partner interested in pursuing relationship therapy, please include their name(s) as well.

What is your email address?

What is the best phone number to reach you at?

Is it okay to leave a voicemail at this number?

Yes

What is your home address?

PLEASE INCLUDE CITY

In what province do you live?

What is your Date of Birth?

What is your partner's Date of Birth?

If you have more than one partner interested in pursuing relationship therapy, please include their DOB(s) next to their name(s) in the text box above.

Please tell us why you're getting in touch.

Please include as much information as you feel comfortable sharing, as this helps us determine which of our therapists would be the best fit for you.

Please keep in mind that this is not asking for your preference of appointment time, but your possible availability for appointments; in most cases, this will mean at least occasionally booking time off during your typical work hours for a scheduled session, much like one would for other health-related appointments (e.g. doctor, dentist, etc.).

If you have a preference of therapist, please select below (please note that we cannot guarantee the availability of any particular therapist):

Claire Beaulne

Offers individual therapy

Katie Campeau

Offers individual therapy and relationship therapy

Melanie Crane

Offers individual therapy

Katherine Wilson

Offers individual therapy, relationship therapy, sex therapy, and ADHD assessments

Do you have extended health benefits coverage? This information helps us determine which of therapists may be the right fit for you.

Yes, for psychological services only.

i.e., services provided by Psychologists

Yes, for psychological AND psychotherapy services.

i.e., services provided by Psychologists and/or Registered Psychotherapists

No, I do not have any extended health benefits coverage.

i.e., I do not intend to submit benefits claims for provided services

I don't know what coverage I have.

Please note that it is your responsibility to clarify the nature of your extended health benefits coverage prior to beginning sessions.

Who is your extended health benefits provider?

(e.g. Canada Life, Manulife, IA Financial, Sun Life, etc.)

Any other information that you'd like for us to be aware of before contacting you about next steps?

If not, please leave blank.

Your information will be encrypted.

Intake form

Mintleaf Psychology Clinic