Therapist Match Form Please choose the option below that best describes why you’re reaching out to us today(Required) Eating Disorder Support Dialectical Behaviour Therapy (DBT) Seeking Other Therapy or Treatment Psychological Assessment Professional Workshops or Training Eating Disorder SupportWhat type of service are you looking for (check all that apply):(Required) Comprehensive Eating Disorder programming Individual Therapy Group Therapy Both Individual + Group Therapy Diagnostic Assessment Dietetic Services Parent Therapy Family Therapy Name of individual completing this form:(Required) First Name Last name • Name of client if different from the person above: First Name Last name Preferred Email Address:(Required)Please note that we will contact you via email typically within 48 business hours of submitting this form. If you do not receive a reply, please be sure to check your spam folder. PhonePlease note that by providing your phone number you consent to us following up via phone as needed.Client Age:(Required) Referral Source:(Required) Please briefly describe your presenting concerns:(Required)Please identify any goals you have for your treatment:(Required)Have you worked with other therapists before?(Required) Yes No If yes, when was your last treatment and why are you looking for alternative care: Please share information about preferred types of approaches or anything you have liked/not liked about treatment in the past:Have you ever been hospitalized for mental health concerns?(Required) Yes No If yes, please share the approximate dates of your hospitalizations and the reason(s) for them: Please provide the name of your physician and any psychiatrist or other professional involved in your mental healthcare: Have you experienced any of the following in the past 6 months (check all that apply):(Required) Suicidal ideation Self-harm Traumatic event Suicide attempt Purging (vomiting following meals, excessive exercise or laxative abuse) Significant caloric restriction Fainting Hospitalization due to mental health concerns None of the above Are you a parent completing this form on behalf of someone under 18? Yes No If yes, are both parents able and willing to consent to the treatment of this child? Yes No Please detail any custody information we must be aware of: If you wish to use private insurance, please detail what type of clinician you have coverage for. Please check all that apply:Please note that we will only offer matches with therapists you have coverage for if you wish to submit receipts to insurance. As such, please check your policy closely. Psychologist Social Worker Psychotherapist Dietitian Occupational Therapist Please list below your general availability for sessions:(Required)Please note that openings for sessions after 4pm or on weekends are extremely rare and requests for these times may result in a substantial wait or referral if we are unable to accommodate you in a timely manner. Flexibility with scheduling facilitates significantly quicker placement. Thank you.Are you interested in virtual or in person sessions: Virtual In person It doesn't matter Is there anything else you would like us to know?Before submitting this form please review the following information: • Sessions at TPWG range between $200 - $270 per session, depending on the clinician and treatment provided • Eating Disorder treatment at TPWG requires an assessment session with a Registered Dietitian within the last 3 months either at our clinic or with a qualified RD specialized in the treatment of Eating Disorders. Further information about this will be provided in your personalized recommendations. • We do not offer the following services: neuropsychology; treatment for children or teens under 12; treatment for individuals with a diagnosis of and/or active psychosis. • If we require any follow-up information beyond what is included on your form we may ask to schedule a call or may follow up via email for further information. • Our recommendations will include details on fees associated with any treatments or programming suggested. • If for any reason we feel that we are unable to support you and your goals we will provide you with specific alternative referrals. • You are most welcome to respond to our email with any questions you may have about our recommendations. Thereafter, we ask that you kindly inform us within 72 hours of receiving our recommendations as to whether you’d like to proceed. After this time we can no longer guarantee that the recommended professional will have space to see you within the timeframe previously outlined. • Upon submitting this form you will receive an email copy of your response. Please note that all forms will be carefully reviewed for suitability of treatment at TPWG. Your personalized recommendations and/or referrals will follow.Thank you for your interest in TPWG. We greatly appreciate your trust and hope to be able to support you in achieving your goals.Dialectical Behaviour Therapy (DBT)What type of service are you looking for (check all that apply):(Required) Individual DBT Therapy Group DBT Therapy Both Individual + + Group Therapy Diagnostic Assessment DBT Parent Therapy DBT Informed Family Therapy Name of individual completing this form: First Name, Last Name(Required) First Last Name of client if different from the person above: First Last Preferred Email Address:(Required)Please note that we will contact you via email typically within 48 business hours of submitting this form. If you do not receive a reply please be sure to check your spam folder. Phone(Required)Please note that by providing your phone number you consent to us following up via phone as needed.Client Age:(Required) Referral Source:(Required) Please briefly describe your presenting concerns:(Required)Please identify any goals you have for your treatment:(Required)Have you worked with other therapists before? Yes No If yes, when was your last treatment and why are you looking for alternative care: Please share information about preferred types of approaches or anything you have liked/not liked about treatment in the past:Have you ever been hospitalized for mental health concerns? Yes No If yes, please share the approximate dates of your hospitalizations and the reason(s) for them: Please provide the name of your physician and any psychiatrist or other professional involved in your mental healthcare: Have you experienced any of the following in the past 6 months (check all that apply):(Required) Suicidal ideation Self-harm Traumatic event Suicide attempt Purging (vomiting following meals, excessive exercise or laxative abuse) Significant caloric restriction Fainting Hospitalization due to mental health concerns None of the above Are you a parent completing this form on behalf of someone under 18? Yes No If yes, are both parents able and willing to consent to the treatment of this child? Please detail any custody information we must be aware of: If you wish to use private insurance, please detail what type of clinician you have coverage for. Please check all that apply:Please note that we will only offer matches with therapists you have coverage for if you wish to submit receipts to insurance. As such, please check your policy closely. Psychologist Social Worker Psychotherapist Dietitian Occupational Therapist Please list below your general availability for sessions:(Required)Please note that openings for sessions after 4pm or on weekends are extremely rare and requests for these times may result in a substantial wait or referral if we are unable to accommodate you in a timely manner. Flexibility with scheduling facilitates significantly quicker placement. Thank you.Are you interested in virtual or in person sessions: Virtual In person It doesn't matter Is there anything else you would like us to know?Before submitting this form please review the following information: • Sessions at TPWG range between $215 - $270 per session, depending on the clinician and treatment provided. • We have DBT groups available for adults (18+), teens (13-17), and caregivers. • You must be working with an individual therapist to participate in our adult or teen DBT groups (this therapist may be part of the TPWG team or may be in the community). • A meeting with one of the group facilitators will be required before joining the teen or adult DBT group. This allows us to understand your reasons for joining group and better support you with achieving your goals. • Our DBT programming does not offer phone coaching or emergency support. • Our recommendations will include details on fees associated with any treatments or programming suggested. • We do not offer the following services: neuropsychology; treatment for children or teens under 12; treatment for individuals with a diagnosis of and/or active psychosis. • If we require any follow-up information beyond what is included on your form we may ask to schedule a call or may follow up via email for further information. • If for any reason we feel that we are unable to support you and your goals we will provide you with specific alternative referrals. • You are most welcome to respond to our email with any questions you may have about our recommendations. Thereafter, we ask that you kindly inform us within 72 hours of receiving our recommendations as to whether you’d like to proceed. After this time we can no longer guarantee thereafter that the recommended professional will have space to see you within the timeframe previously outlined. • Upon submitting this form you will receive an email copy of your response. Please note that all forms will be carefully reviewed for suitability of treatment at TPWG. Your personalized recommendations and/or referrals will follow. Thank you for your interest in TPWG. We greatly appreciate your trust and hope to be able to support you in achieving your goals.Seeking Other Therapy or SupportWhat type of service are you looking for (check all that apply):(Required) Individual Therapy Couples Therapy Family Therapy Group Therapy Parent Therapy Both Individual + Group Therapy Diagnostic Assessment Name of individual completing this form: First Name, Last Name(Required) First Last Name of client if different from the person above: First Last Preferred Email Address:(Required)Please note that we will contact you via email typically within 48 business hours of submitting this form. If you do not receive a reply please be sure to check your spam folder. PhonePlease note that by providing your phone number you consent to us following up via phone as needed.Client Age(Required) Referral Source(Required) Please briefly describe your presenting concerns:(Required)Please identify any goals you have for your treatment:(Required)Have you been in similar treatment before (e.g., therapy, couples treatment or dietetic support)?(Required) Yes No If yes, please note who you saw, for how long, and why are you looking for alternative care at this time: Please share information about preferred types of approaches or anything you have liked/not liked about treatment in the past: Have you ever been hospitalized for mental health concerns?(Required) Yes No If yes, please share the approximate dates of your hospitalizations and the reason(s) for them. Please provide the name of your physician and any psychiatrist or other professional involved in your mental healthcare:(Required) Have you experienced any of the following in the past 6 months (check all that apply):(Required) Suicidal ideation Self-harm Traumatic event Suicide attempt Purging (vomiting following meals, excessive exercise or laxative abuse) Significant caloric restriction Fainting Hospitalization due to mental health concerns None of the above • Are you a parent completing this form on behalf of someone under 18? Yes No If yes, are both parents able and willing to consent to the treatment of this child? Please detail any custody information we must be aware of: If you wish to use private insurance, please detail what type of clinician you have coverage for. Please check all that apply:Please note that we will only offer matches with therapists you have coverage for if you wish to submit receipts to insurance. As such, please check your policy closely. Psychologist Social Worker Psychotherapist Dietitian Occupational Therapist Please list below your general availability for sessions:(Required)Please note that openings for sessions after 4pm or on weekends are extremely rare and requests for these times may result in a substantial wait or referral if we are unable to accommodate you in a timely manner. Flexibility with scheduling facilitates significantly quicker placement. Thank you.Are you interested in virtual or in person sessions: Virtual In person It doesn't matter Is there anything else you would like us to know?(Required)Before submitting this form please review the following information: • Individual sessions at TPWG range between $200 - $270 per session, depending on the clinician and treatment provided. • Our recommendations will include details on fees associated with any treatments or programming suggested. • We do not offer the following services: neuropsychology; treatment for children or teens under 12; treatment for individuals with a diagnosis of and/or active psychosis. • If we require any follow-up information beyond what is included on your form we may ask to schedule a call or may follow up via email for further information. • If for any reason we feel that we are unable to support you and your goals we will provide you with specific alternative referrals. • You are most welcome to respond to our email with any questions you may have about our recommendations. Thereafter, we ask that you kindly inform us within 72 hours of receiving our recommendations as to whether you’d like to proceed. After this time we can no longer guarantee thereafter that the recommended professional will have space to see you within the timeframe previously outlined. • Upon submitting this form you will receive an email copy of your response. Please note that all forms will be carefully reviewed for suitability of treatment at TPWG. Your personalized recommendations and/or referrals will follow. Thank you for your interest in TPWG. We greatly appreciate your trust and hope to be able to support you in achieving your goals.Psychological AssessmentWhat type of service are you looking for (check all that apply)?(Required) Psychoeducational Assessment (including for learning disabilities) ADHD Assessment Diagnostic Clarification Assessment Name of individual completing this form: First Name, Last Name(Required) First Last Name of client if different from the person above: First Last Preferred Email Address:(Required)Please note that we will contact you via email typically within 48 business hours of submitting this form. If you do not receive a reply please be sure to check your spam folder. PhonePlease note that by providing your phone number you consent to us following up via phone as needed.Client Age:(Required) Referral Source:(Required) Please briefly describe your presenting concerns:(Required)Have you ever had an assessment before?(Required) Yes No If yes, please share further details about who completed the assessment and when: Have you been given any previous mental health diagnoses?(Required) Yes No If yes, please share further details: Have you ever been hospitalized for mental health concerns?(Required) Yes No If yes, please share the approximate dates of your hospitalizations and the reason(s) for them: Please provide the name of your physician and any psychiatrist or other professional involved in your mental healthcare:(Required) Have you experienced any of the following in the past 6 months (check all that apply):(Required) Suicidal ideation Self-harm Traumatic event Suicide attempt Disordered Eating None of the above Are you a parent completing this form on behalf of someone under 18? Yes No If yes, are both parents able and willing to consent to the assessment of this child? Please detail any custody information we must be aware of: If you wish to submit receipts to your insurance, please let us know of any details pertaining to your coverage: Is there anything else would like us to know?Before submitting this form please review the following information: • All assessments are completed by clinicians on our psychology team. • The fees for psychological assessments vary depending on the type of assessment required. Our recommendations will include details on fees associated with any treatments or programming suggested. • We do not offer the following services: neuropsychology; treatment for children or teens under 12; treatment for individuals with a diagnosis of and/or active psychosis. • If we require any follow-up information beyond what is included on your form we may ask to schedule a call or may follow up via email for further information. • If for any reason we feel that we are unable to support you and your goals we will provide you with specific alternative referrals. • You are most welcome to respond to our email with any questions you may have about our recommendations. Thereafter, we ask that you kindly inform us within 72 hours of receiving our recommendations as to whether you’d like to proceed. After this time we can no longer guarantee thereafter that the recommended professional will have space to see you within the timeframe previously outlined. • Upon submitting this form you will receive an email copy of your response. Please note that all forms will be carefully reviewed for suitability of treatment at TPWG. Your personalized recommendations and/or referrals will follow. Thank you for your interest in TPWG. We greatly appreciate your trust and hope to be able to support you in achieving your goals.Professional Workshop or TrainingWhat type of service are you looking for (check all that apply):?(Required) Professional Workshop Training Speaking Engagement Group Consultation Other Name of individual completing this form:(Required) First Last Preferred email address:(Required)Please note that we will contact you via email typically within 48 business hours of submitting this form. If you do not receive a reply please be sure to check your spam folder. Phone:Please note that by providing your phone number you consent to us following up via phone as needed.Referral Source:(Required) Please briefly describe what you are looking for:(Required)Organization name (if applicable): Approximate audience size (if applicable): Method of delivery: Virtual In Person If in person – address: Approximate Budget (if applicable): Is there any further information you think we should know?Thank you for your interest in TPWG. We look forward to connecting with you soon!
