Request for Service

Date of Birth *

MM

DD

YYYY

Name *

First Name

Last Name

Contact Telephone *

(###)

###

####

Alternate Telephone

(###)

###

####

Employer *

If you are an employee at any of the following companies, please select the appropriate button and provide your employee number below (if applicable).

FIO Automotive

FAG / Schaeffler Canada Inc

Perth Community Futures Development Corporation

Wallenstein Feed & Supply

Other

Method of Payment *

INSURANCE / BENEFIT PLAN COVERAGE Please check your insurance plan under 'Paramedical Benefits' to ensure reimbursement. It is YOUR responsibility to make the correct selection of what your plan covers. PLEASE SELECT ALL OF THE FOLLOWING OPTIONS THAT APPLY :

Registered Psychologist

Registered Psychotherapist

Registered Social Worker

No Insurance Benefits

Day(s) of the Week Preferred *

Please select ALL of the days that you are available. Please note that most therapists conduct sessions between 9am - 5pm.

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Time of Day preference *

daytime

evening

no preference

How soon would you like to have a session? *

within 2 weeks

within 4 weeks

more than 4 weeks

no preference

Preferred Therapist Gender *

No Preference

Male

Female

Preference regarding type of session *

in-person

virtual

no preference