Contact Form

Name

Email address

Phone

City and province of residence

Age of person needing service

1. Please briefly describe reasons for seeking an appointment (e.g., depression, anxiety, anger, interpersonal conflict, stress at work etc).

2. Do you have extended health benefits coverage? If you do, is it for psychologists or counselors or both?

3. If you do not have extended health benefits, are you willing to see a a clinician who is not a registered psychologist but is working under the supervision of a registered psychologist for a lower fee?

4. What’s your general availability for appointments on weekdays? What’s the earliest time you can arrive at our office?

5. Do you prefer online or in-person appointments?

6. If you are requesting an in-person appointment, do you prefer to see a clinician out of our Broadway/City-Hall or Central Park location?

7. If we have no availablity at your preferred location, are you willing to travel to our other office location if there is a clinician available?

8. How did you hear about us (e.g., Google, word of mouth, other treatment provider, Psychology Today, Lumino Health, BC Psychological Association, etc.)?

If there is any additional information that you would like us to know, please state below:

By completing this form you are agreeing to our clinic's Privacy Policy. Information we collect on this form is shared with our clinical team to help us identify potential clinicians for you to work with. We will never sell your information to third parties.

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