FULL NAME (*)
PHONE NUMBER (*)
EMAIL (*)
SERVICES REQUESTED (*)
AVAILABILITY
TREATMENT LANGUAGE
PREFERRED THERAPIST
PREFERRED DAY AND TIME (NOT GUARANTEED)
DATE OF BIRTH (*)
PLEASE DESCRIBE WHY YOU ARE SEEKING SERVICES:
(*)
If you are experiencing an emergency situation, you can call the Mental Health Crisis Line (bilingual) 24 hr service 613-722-6914 * Toll free 1-866-996-0991 or present yourself at the nearest emergency room or call 911.
