Returning client? Book here New client? Please complete the form below. Name * First Name Last Name Email * Preferred Pronouns * she/her he/him they/them prefer not to say other (list in space below) Home Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Do you consent for a voicemail to be left at this address * Yes No Date of Birth * MM DD YYYY Current medication(s) if applicable: Family physician (if applicable): Emergency contact: * Include: full name, phone number, and relationship to you What practitioner would you like to meet with? * Angelina MacLellan-Muise (Psychologist) Andrea Krygier (Psychologist) Mary Jane Neitz (Counselling Therapist) Any - Match me to the best fit! Briefly describe the referral concern, including examples and symptoms (3-4 sentences): * What is your modality preference for meeting with your Psychologist? * Virtually (video/phone) In person Either Do you know of any first-order relatives (i.e. parents, children, partners or ex-partners, etc.) that have been or may be clients of our office? * Yes No Please let us know how you found our practice or who referred you: In the case of Couples Therapy we also need the following fields (for spouse/partner): Name First Name Last Name Date of Birth MM DD YYYY Email I confirm that I am seeking psychological services for myself. I understand that I cannot seek psychological services on behalf of another person (e.g., friend, partner, family member, etc.) Thank you!We’ll be in touch with you soon to book your first session. If you do not hear from us in one to two business days, please check your spam and/or junk folder! Self-Referral Form
