Name *

First Name

Last Name

Phone *

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do you have or suspect you have any of the conditions below? *

Depression / low mood

Any type of anxiety

Schizophrenia / psychosis

Bipolar disorder

Preferred consultation method *

In-clinic at Binbrook, ON (near Hamilton)

Virtual through video conference or phone

I understand this service is to address my mental health concerns. *

I understand

I understand that the initial consultations (approximately 30 minutes) are free and follow-up consultations (approximately 20 mins) are $48 (follow-ups are optional). If I cannot make an appointment, I agree to notify the clinic 24 hrs in advance to cancel or reschedule or pay a $48 fee for no-show *

I understand