Silm Centre for Mental Health Intake Form
Thank you for your interest in services at Silm Centre for Mental Health. Please fill out this secure form so that we can match you with the right therapist. 

If you don't know how to answer a question, that's okay. Just fill this out to the best of your knowledge.

If you would rather speak to someone over the phone to share this information, you may do this instead by calling 416-384-1111 or emailing admin@silmmentalhealth.com.

We will always offer you a free consult with your potential therapist to ensure that they are the right person for you to work with. After your consult, you will have the opportunity to schedule a session, to take some time to think about it, or to speak with someone else.

Thank you for trusting us on your mental health journey. We aim to get back to you within 24-48 hours.

Please note that we are not a crisis service. If you are in crisis, please call 911, visit your closest emergency room, or call the Distress Centre of Toronto (416-408-4357)
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Email *
Your Name (and client's name, if you are filling this out on behalf of someone else) *
Age of client(s) to be receiving services
Gender pronouns of client(s) to be receiving services (e.g., she, them, he)
Your Phone Number
 *
Is it OK to leave a voicemail?
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Email Address
 *
Preferred method of contact
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What services are you interested in?
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What concerns would you like addressed? Feel free to include as much or as little as you would like (e.g., anxiety, emotion regulation, PTSD, relationships, depression, etc.)
Sometimes people prefer a therapist with certain characteristics (e.g., a therapist who is a person of colour, a male, someone under 40, etc.). Do you have any preferences for your therapist? This will help us ensure we are matching you as well as we can. You may also leave this blank if you have no therapist preferences.
Your answer

Are there any specific modalities (e.g., CBT, DBT, ACT) of therapy you would be interested in? If you're not sure, you don't need to include any information here.
If you are using extended health benefits, which of the following are covered?
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The cost of psychotherapy ranges from $180 to $275 per 50 minute session. In thinking about your insurance and your budget, do you have any preferences regarding the rate of psychotherapy? Note that the different fee rates vary by type of professional and experience.
We also have student therapists that are closely supervised by Dr. Taslim. Their fees for psychotherapy are $90 per 50 minute session. Would you be interested in seeing a student therapist? Please note that seeing a student would be covered by extended health benefits under psychology services.
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Do you have access to any third-party funding? If yes, which of the following applies.
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In terms of scheduling, what kind of appointment times would you need?
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Are you looking for in-person services?
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How did you hear about us?
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If you were referred by your physician or another health professional, kindly include their name. Please note that we gather this information for our own record keeping, and will not be reaching out to them without your consent.
Feel free to add anything else you would like to share with us.
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