Child In Mind - Therapeutic Services- Waitlist

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Our team of clinicians provides therapeutic & counselling services to children, teens, parents, adults, couples and families. Prior to completing this form, we encourage you to review the bios of the clinicians listed under "Clinicians With Immediate Availability" on our website www.childindmind.com. If you do not see a clinician that is suitable for your, or your family's needs, please complete this form and you will receive an invitation to book a free 15mins virtual appointment to assess your needs and determine next steps.

Please note - we are experiencing a high number of referrals at this time. We do our absolute best to support children and families as soon as we possibly can! We know it is hard to wait when your child is struggling. We completely understand are working hard to meet the demand for services. We thank you for your patience!

Email *

Name of Parent 1 *

Phone Number of Parent 1

Name of Parent 2

Email of Parent 2

Are you a resident of Ontario? If not, unfortunately we are unable to provide services to your family due to Provincial restrictions. *

Yes, I am a resident of Ontario

No, I am not a resident of Ontario

Are there custody agreements relating to decision making authority? **We require consent from all guardians to provide psychological services to your child** In cases of sole decision making authority, please forward documentation to info@childinmind.com *

Guardians are married and live in the same home

Guardians are separated and have shared decision making authority

Guardians are separated, one of whom has sole decision making authority

There is only one legal guardian

For families where shared consent is required, we require both parents consent and/or a copy of the court order indicating sole decision making authority. Child In Mind will not provide services to children until consent is received from all guardians. We will request a copy of the order when you have been assigned to a clinician. *

I acknowledge consent is required

Not Applicable

Name of Child *

Age of Child

Child's Date of Birth *

YYYY

What type of support are you seeking for your child/family? (e.g., child therapy, parent support, family therapy) *

Please provide a brief description of your concerns *

Are you requesting a specific clinician? If so, please let us know who you hope to work with. (Note: Dr. Matheson is not accepting new referrals at this time)

Would you like us to contact you with an appointment when we have a last minute cancellation? *

Yes

Are you open to virtual services exclusively? Some of our clinicians are offering virtual services only. *

Open to virtual services

Need in-person services

Either virtual or in-person will work for my family

I'm not sure but open to the clinic's suggestion regarding my family's needs

Were you referred by someone? If so, please add name of individual or professional.

Send me a copy of my responses.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of Child In Mind. Report Abuse

Forms