Intake form

Still have questions? Email us at admin@mintleafclinic.com or call us at (613) 223-5613 for more info.

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/text 9-8-8 to reach a 24/7/365 crisis support line.

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 Psychotherapy

Couple's & Relationship Therapy

Sex Therapy (individual)

Sex Therapy (relationship)

ADHD Assessment

ADHD Coaching & Psychotherapy

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 name(s)?

Please include pronouns

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?

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 below.

Please tell us why you're getting in touch.

At this time, do you have a sense of your preference regarding session frequency? Please note: decisions about session frequency and treatment approach will be collaboratively reached with your therapist. While we do our best to offer as frequent sessions as each client would like, we cannot guarantee that our therapists will be able to accommodate your scheduling preferences.

Weekly

Every other week

Monthly

Every few months

Only as-needed

I am flexible and/or unsure of my preference

Other

If you selected Other, please briefly describe below:

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, couple's & relationship therapy, and sex therapy

Melanie Crane

Offers individual therapy and ADHD coaching/psychotherapy

Amanda Van Geel

Offers individual therapy, couple's & relationship therapy, and sex therapy

Katherine Wilson

Offers individual therapy, couple's & 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 Registered Psychologists

Yes, for psychological AND psychotherapy services.

i.e., services provided by Registered 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

Still have questions? Email us at admin@mintleafclinic.com or call us at (613) 223-5613 for more info.

Still have questions? Email us at admin@mintleafclinic.com or call us at (613) 223-5613 for more info.

Mintleaf Psychology Clinic