Request an appointment This form will help us assign you to the right therapist according to your needs and availabilities. Please note that this process may take from 2 weeks, up to 12 weeks depending on our openings at that time. If you have any questions about our waitlist, please email us at firstname.lastname@example.org 1 About You2 How Can We Help3 Appointment Details Name* First Last Phone*Email* Is this for a child?*YesNoHow old is the client?*What is your marital status*- select an option -SingleIn a relationshipMarried/Common lawWhat is your occupation at the moment?*StudentWorking part timeWorking full time What is the reason for your consultation?* Stress/Anxiety Depressed mood Relationship problems Burnout Anger management Issues related to food/eating Work/career concerns Coping with physical illness ADHD Other Other reason for consultation*When did this difficulty begin?*- select an option -A few weeks agoA few months agoA few years agoMany years agoWhat type of therapy are you interested in?* Cognitive Behaviour Therapy Mindfulness-Based Therapy Acceptance and Commitment Therapy Emotion-Focused Therapy Dialectical Behaviour Therapy Couples therapy I don't know Have you ever consulted with a mental health professional before?*NeverI've seen one or 2 therapistsI've seen more than 2 therapistsAre you taking any psychiatric medication?*YesNoHave you ever attempted suicide?*YesNoHave you attempted any self-injury in the last few months?*YesNo When are you available to meet your therapist?* Monday during the day (8am to 4pm) Monday evening (5pm to 8pm) Tuesday during the day (8am to 4pm) Tuesday evening (5pm to 8pm) Wednesday during the day (8am to 4pm) Wednesday evening (5pm to 8pm) Thursday during the day (8am to 4pm) Thursday evening (5pm to 8pm) Friday during the day (8am to 4pm) Friday evening (5pm to 8pm) You can select more than oneAt which MindSpace location(s) are you willing to attend meetings?* I can go to any office Westmount (Greene avenue) Outremont (Laurier west) Downtown (Peel) You can select more than oneWhat is your preferred language for therapy*EnglishFrenchI am bilingualHow did you hear about Mindspace?*- select an option -Referral from physician (if so, please indicate the name of your physician in the section below)Referral from other health professionalReferral from a friend, colleague, or family memberWeb searchSocial mediaMailing listConference or public appearance by MindSpace staffMedia appearance by MindSpace staffNotes Submit This iframe contains the logic required to handle Ajax powered Gravity Forms.