form 1➜ Full Name2➜ Email Address *3➜ Phone Number *4➜ What is the primary reason you’re seeking therapy? (Select one) *Anxiety or stress managementDepressionRelationship issuesTrauma or PTSDGrief or lossSelf-esteem or personal growthAddiction or substance useWork-related stressFamily conflictsLife transitionsOther5➜ Which province or territory do you live in? *Type or select an optionAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon6➜ What type of psychotherapy are you interested in? (Select all that apply) *Choose as many as you likeIndividual TherapyCouples TherapyChild/ Youth TherapyEMDR (Eye Movement Desensitization and Reprocessing)DBR (Deep Brain Reorienting)Not sure (would like therapist recommendations)7➜ What is your preferred method of payment? *Insurance/ Employer benefitsSelf-pay (out-of-pocket)Combination of insurance and self-payNot sure yet8➜ If using insurance, which insurance company are you covered by?9➜ What is your annual insurance policy maximum for mental health services? *Less than $500$500 – $1,000$1,001 – $2,000$2,001 – $5,000More than $5,000UnlimitedI don’t know (I’ll check with my provider)Not applicable10➜ What is your co-pay amount per therapy session? *No co-pay (100% coverage)Less than $50$50 – $100More than $100Percentage based co-insuranceI don’t know (I’ll check with my provider)Not applicable11➜ If self-pay, what is your estimated monthly budget for therapy? *Less than $100$100 – $200$201 – $300$301 – $400$401 – $500More than $500Prefer sliding scale optionsNot applicable12➜ What is your language preference for therapy sessions? (please specify)OK