Self Referral Therapy Form

Self referral therapy form is a form that you fill out if you wish to admit yourself as a client/patient for therapy.

Clients can also self book on our therapy online booking calendar.

Self Referral Therapy Form

PERSONAL INFORMATION

First name

Last name

Phone

Your preference for contact

AVAILABILITY & SCHEDULING FOR FIRST SESSION

Weekdays mornings before 12pm

Weekdays afternoons between 12pm and 5pm

Weekdays evenings after 5pm

Weekend mornings before 12pm

Weekend afternoons between 12pm and 5pm

Weekend evenings after 5pm

Additional information about your schedule, if needed.

Please specify any exact times and days you wish to have your first therapy session.

When do you wish to have your first session?

TREATMENT PLANNING

What brings you to therapy ?

What are your therapy goals ?

Have you had therapy before ? What was your experience like ?

How can we improve your experience, or what do you think therapy and your therapist should be like?

Additional Treatment Planning

Do you have insurance ?

If yes, please share your insurance coverage amount: Knowing your coverage amount helps us to better understand your needs and create a treatment plan that fits within your benefits to ensure you receive the most supportive and effective care.

I understand this is a short form to facilitate my quick admission, and there will be additional forms for consent, terms and conditions, and others that may arise specific to my case, that are mandatory.

I agree to the terms and conditions.

Signature

Any additional information you wish to add.

Additional Information if you wish to submit.