Clinic  
  • Queen Elizabeth Health Complex
    2100 Marlowe
    Suite 626
    Montreal, Qc, H4A 3L6
    514-482-3327

Appointment Form

Intake Date
*First Name *Last Name

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Date of Birth
mm/dd/yyyy
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*Email

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Address
City Postal Code
Home Phone  

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Work Phone

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Cell Phone

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For reasons of confidentiality, please advise us if we can leave a message at the numbers you have provided.
Home
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Work
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Cell
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Language
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*Request For
Individual Therapy Family/Child/Adolescent

What is your availability for scheduling sessions? Please indicate all times during which you are available for scheduling. Be as specific as possible. Eg. Mondays: morning, afternoon, evening, etc.
*Employment Occupation
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Couples (optional)
Partner's Name
Partner's Age
Partner's Phone
Partner's Employment Partner's Occupation


Are you covered by Insurance		 Yes No

Marital Status

Referral Source

*In Current Psychological/Psychiatric Treatment
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*Previous Psychological Treatment
Yes No
If you answered yes to the last question, what was the duration?
Please provide a brief description of the current presenting issue and any other information to help us match you with a suitable professional:
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