New Client Form | One Psychology

Client First Name

Client Last Name

Email

Client Age

Client Gender

Are you completing this form on behalf of someone else (such as a child)?

No

Yes - please add your name:

Are you looking for virtual or in-person sessions?

Virtual

In-person

Both work for me

Which registered health professionals are covered under your insurance? We strongly recommend checking with your insurance plan prior to starting. Please check all that apply.

Please provide the amount of insurance coverage you have:

Briefly describe your presenting concerns:

Identify goals you would have for therapy/assessment:

Have you had therapy/assessment in the past?

Yes

No

Have you ever been hospitalized for mental health reasons?

Yes

No

Have you experienced any of the following in the past six months?

Suicidal ideation

Suicide attempt

Self-harm

Traumatic event

Disordered eating (e.g., purging, significant restriction, laxative abuse, excessive exercise)

Please list your general availability for sessions (days & times):

Is there any additional information you would like us to know?

Before submitting this form, please review the following information:

If we require any follow-up information, we may ask to schedule a brief call or follow up via e-mail for further information.
Please expect to hear back from us within 24 hours with a therapist and/or treatment recommendation.
Individual sessions range between $225 - $270 per session, depending on the clinician and treatment provided. Groups are $100 per session.
If we are unable to support you, we will do our best to provide you with alternative referrals.
Please note that e-mail and contact forms are not secure forms of communication. Your use of this contact form confirms that you accept this risk.