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Consent Form

To confirm your appointment, please complete and submit the consent form below, along with your client information.

Client Information Form
Address
Address
Street Address
Apartment/Suite/Unit Number (if applicable)
City
Province
Postal Code
Gender
Marital Status

Our clinic takes a systemic approach to therapy, so it is essential that both parents are willing to work together in order to provide the best possible care for their child. If you are submitting this information on behalf of a child under the age of 14 years old, you must meet the following criteria in order for us to accept your case:

- You have informed and obtained consent from the other parent or legal guardian, if one exists;

- You must be on speaking terms and able to collaborate with the other parent or legal guardian, if one exists.

Do you satisfy these criteria?
We do not accept court-mandated cases. Have you been mandated by a court?
We do not accept court-mandated cases.
You may cancel your appointment without charge, if you cancel it at least 24 hours in advance. In the event that you cancel within 24 hours of your appointment, do you agree to pay the session fee?
Do you agree to have the cancellation fee charged on your credit card?
I have read, understood, and agreed to the terms of service (TOS). I further understand that the "SUBMIT" button is the electronic equivalent of my signature. By clicking it, I am authenticating and binding my agreement of the TOS.