Treatment Program at the DECODE Insomnia Clinic Interest Form

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Please complete this form if you (or your teen/youth) is interested in participating in the DECODE Insomnia Program, delivered through the DECODE Insomnia Clinic.

The information collected below is to establish if this is a good fit before an intake conversation with the program coordinator.

If you would rather not complete this form, please send your responses to the questions below to decodeinsomnia@protonmail.com.

What is your name? Please enter your initials if preferred. *

I am

an interested youth participant (13-26y)

an interested parent participant and have a youth between the age of 13-18

Clear selection

If you are a parent, what is the youth's name or initials?

I am/the interested youth participant is between the ages of 13-26.

Yes

Clear selection

I am/the interested youth participant is a resident of Ontario with a valid OHIP card.

Yes

Clear selection

Have you already been seen in consultation by Dr. Ooi at the Toronto Sleep Institute?

Yes

Clear selection

I understand that this program provides a comprehensive treatment approach for insomnia and is not intended for those looking for general advice or sleep investigations. I understand that there is a program fee for participation and access to the online portal* and that, if I also wish to proceed with the OHIP-covered appointments, a physician referral will be requested before confirming the initial clinic appointment.

*Financial options available.

Yes

Clear selection

*I would like to discuss financial options with the program coordinator.

Yes

Clear selection

Please enter the best way of contacting you to arrange an intake conversation with the program coordinator. Feel free to provide more than one method of contact. (ex. email example@example.com or cell 111-111-1111 after 3pm on weekdays).

Please enter any other questions or comments in the space below. *

Thank you very much for submitting this form. You will be contacted shortly by the program coordinator.

Submit

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