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

Psychoeducational Assessment

Professional Workshops or Training

Eating Disorder Support

What 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)

• Name of client if different from the person above:

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)

Client Pronouns:(Required)

Referral Source (please provide a specific name where possible):(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

If yes, when was your last treatment and why are you looking for alternative care:(Required)

Please share information about preferred types of approaches or anything you have liked/not liked about treatment in the past:(Required)

Have you ever been hospitalized for mental health concerns?(Required)

Yes

If yes, please share the approximate dates of your hospitalizations and the reason(s) for them:(Required)

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

You selected "Fainting" - please indicate your reason for fainting:(Required)

Are you being monitored by a physician currently?(Required)

Yes

Physician Name and Contact:(Required)

Are you interested in meeting with a physician or nurse practitioner for a medical assessment and/or to discuss medication for mental health purposes?(Required)

Yes

Are you a parent completing this form on behalf of someone under 18?(Required)

Yes

If yes, are both parents able and willing to consent to the treatment of this child?(Required)

Yes

If caregivers/parents will be paying for sessions, please include their email addresses here:(Required)

Please note that by providing their email addresses, you are providing consent for us to contact them with our fee outline and payment information.

Please detail any custody information we must be aware of:(Required)

If you wish to use private insurance, please detail what type of clinician you have coverage for. Please check all that apply:(Required)

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

I do not have/will not be using insurance.

Please provide the amount of insurance coverage you have for the aforementioned provider types:(Required)

Please list below your general availability for sessions:(Required)

Please note that openings for sessions after 3 pm 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.

I am able to and willing to be flexible for morning or daytime sessions (i.e 9am-2pm) if no evening times are currently available:(Required)

Yes

Are you interested in virtual or in person sessions:(Required)

Virtual

In person

It doesn't matter

Are you currently residing in Ontario?(Required)

Yes

If no, where are you currently residing?(Required)

Is there anything else you would like us to know?(Required)

Before submitting this form please review the following information:

• Sessions at TPWG range between $220 - $300 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 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)

Name of client if different from the person above:

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)

Client Pronouns:(Required)

Referral Source (please provide a specific name where possible):(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

If yes, when was your last treatment and why are you looking for alternative care:(Required)

Please share information about preferred types of approaches or anything you have liked/not liked about treatment in the past:(Required)

Have you ever been hospitalized for mental health concerns?(Required)

Yes

If yes, please share the approximate dates of your hospitalizations and the reason(s) for them:(Required)

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

You selected "Fainting" - please indicate your reason for fainting:(Required)

Are you being monitored by a physician currently?(Required)

Yes

Physician name and contact:(Required)

Are you interested in meeting with a physician or nurse practitioner for a medical assessment and/or to discuss medication for mental health purposes?(Required)

Yes

Are you a parent completing this form on behalf of someone under 18?(Required)

Yes

If yes, are both parents able and willing to consent to the treatment of this child?(Required)

If caregivers/parents will be paying for sessions, please include their email addresses here:(Required)

Please note that by providing their email addresses, you are providing consent for us to contact them with our fee outline and payment information.

Please detail any custody information we must be aware of:(Required)

If you wish to use private insurance, please detail what type of clinician you have coverage for. Please check all that apply:(Required)

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

I do not have/will not be using insurance.

Please provide the amount of insurance coverage you have for the aforementioned provider types:(Required)

Please list below your general availability for sessions:(Required)

I am able to and willing to be flexible for morning or daytime sessions (i.e 9am-2pm) if no evening times are currently available:(Required)

Yes

Are you interested in virtual or in person sessions:(Required)

Virtual

In person

It doesn't matter

Are you currently residing in Ontario?(Required)

Yes

If no, where are you currently residing?(Required)

Is there anything else you would like us to know?(Required)

Before submitting this form please review the following information:

• Sessions at TPWG range between $220 - $300 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 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 Support

What 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)

Name of client if different from the person above:

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)

Client Pronouns:(Required)

Referral Source (please provide a specific name where possible):(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

If yes, please note who you saw, for how long, and why are you looking for alternative care at this time:(Required)

Please share information about preferred types of approaches or anything you have liked/not liked about treatment in the past:(Required)

Have you ever been hospitalized for mental health concerns?(Required)

Yes

If yes, please share the approximate dates of your hospitalizations and the reason(s) for them.(Required)

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

You selected "Fainting" - please indicate your reason for fainting:(Required)

Are you being monitored by a physician currently?(Required)

Yes

Physician name and contact:(Required)

Are you interested in meeting with a physician or nurse practitioner for a medical assessment and/or to discuss medication for mental health purposes?(Required)

Yes

• Are you a parent completing this form on behalf of someone under 18?(Required)

Yes

If yes, are both parents able and willing to consent to the treatment of this child?(Required)

If caregivers/parents will be paying for sessions, please include their email addresses here:(Required)

Please note that by providing their email addresses, you are providing consent for us to contact them with our fee outline and payment information.

Please detail any custody information we must be aware of:(Required)

If you wish to use private insurance, please detail what type of clinician you have coverage for. Please check all that apply:(Required)

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

I do not have/will not be using insurance.

Please provide the amount of insurance coverage you have for the aforementioned provider types:(Required)

Please list below your general availability for sessions:(Required)

I am able to and willing to be flexible for morning or daytime sessions (i.e 9am-2pm) if no evening times are currently available:(Required)

Yes

Are you interested in virtual or in person sessions:(Required)

Virtual

In person

It doesn't matter

Are you currently residing in Ontario?(Required)

Yes

If no, where are you currently residing?(Required)

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 $220 - $300 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 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 Assessment

What type of service are you looking for (check all that apply)?(Required)

ADHD Assessment

Diagnostic Clarification Assessment

Name of individual completing this form: First Name, Last Name(Required)

Name of client if different from the person above:(Required)

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)

Client Pronouns:(Required)

Referral Source (please provide a specific name where possible):(Required)

Please briefly describe your presenting concerns:(Required)

Have you ever had an assessment before?(Required)

Yes

If yes, please share further details about who completed the assessment and when:(Required)

Have you been given any previous mental health diagnoses?(Required)

Yes

If yes, please share further details:(Required)

Have you ever been hospitalized for mental health concerns?(Required)

Yes

If yes, please share the approximate dates of your hospitalizations and the reason(s) for them:(Required)

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 being monitored by a physician currently?(Required)

Yes

Physician name and contact:(Required)

Are you interested in meeting with a physician or nurse practitioner for a medical assessment and/or to discuss medication for mental health purposes?(Required)

Yes

Are you interested in medical monitoring or consultation with a physician or NP at the clinic?(Required)

Yes

Are you a parent completing this form on behalf of someone under 18?(Required)

Yes

If yes, are both parents able and willing to consent to the assessment of this child?(Required)

If caregivers/parents will be paying for sessions, please include their email addresses here:(Required)

Please note that by providing their email addresses, you are providing consent for us to contact them with our fee outline and payment information.

Please detail any custody information we must be aware of:(Required)

If you wish to submit receipts to your insurance, please let us know of any details pertaining to your coverage:(Required)

Are you currently residing in Ontario?(Required)

Yes

If no, where are you currently residing?(Required)

Is there anything else would like us to know?(Required)

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 currently conduct assessments where the primary inquiry is for Autism Spectrum Disorder (ASD). We are able to screen for the possibility of symptoms that warrant further investigation as part of our assessments and may make a diagnosis where appropriate, but do not provide comprehensive standalone assessments for ASD in children or adolescents at this time.

• We do not offer the following services: neuropsychology; 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.

Psychoeducational Assessment

What type of service are you looking for (check all that apply)?(Required)

Psychoeducational Assessment (including for learning disabilities)

ADHD Assessment

Name of individual completing this form: First Name, Last Name(Required)

Name of client if different from the person above:(Required)

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)

Client Pronouns:(Required)

Referral Source (please provide a specific name where possible):(Required)

Client date of birth:(Required)

Client's current school:(Required)

Client's current grade in school:(Required)

If you are the parent of an individual under 18 seeking services and there are custody arrangements involved, please detail these here. Please note we will need consent of both parties where shared custody is involved:(Required)

Names of individuals who will be involved in the assessment:(Required)

Referral Source:(Required)

Presenting issues for which assessment is being sought. Please offer specific details and list questions you may have:(Required)

Have you have any previous diagnoses? If so, please share details including approximate diagnosis date and information about who made the diagnosis:(Required)

Have you ever had an assessment before?(Required)

Yes

If yes, Please provide details of any previous assessments including the approximate date, purpose, and the psychologist or clinician who completed it:(Required)

Have you been given any previous mental health diagnoses?(Required)

Yes

If yes, please share further details:(Required)

Have you ever been hospitalized for mental health concerns?(Required)

Yes

If yes, please share the approximate dates of your hospitalizations and the reason(s) for them:(Required)

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 being monitored by a physician currently?(Required)

Yes

Physician name and contact:(Required)

Are you interested in meeting with a physician or nurse practitioner for a medical assessment and/or to discuss medication for mental health purposes?(Required)

Yes

Are you a parent completing this form on behalf of someone under 18?(Required)

Yes

If yes, are both parents able and willing to consent to the assessment of this child?(Required)

If caregivers/parents will be paying for sessions, please include their email addresses here:(Required)

Please note that by providing their email addresses, you are providing consent for us to contact them with our fee outline and payment information.

Please detail any custody information we must be aware of:(Required)

If you wish to submit receipts to your insurance, please let us know of any details pertaining to your coverage:(Required)

Are you currently residing in Ontario?(Required)

Yes

If no, where are you currently residing?(Required)

Is there anything else would like us to know?(Required)

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 currently conduct assessments where the primary inquiry is for Autism Spectrum Disorder (ASD). We are able to screen for the possibility of symptoms that warrant further investigation as part of our assessments and may make a diagnosis where appropriate, but do not provide comprehensive standalone assessments for ASD in children or adolescents at this time.

• We do not offer the following services: neuropsychology; 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 Training

What 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)

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.

Referral Source:(Required)

Please briefly describe what you are looking for:(Required)

Organization name (if applicable):(Required)

Approximate audience size (if applicable):(Required)

Method of delivery:(Required)

Virtual

In Person

If in person – address:(Required)

Approximate Budget (if applicable):(Required)

Is there any further information you think we should know?(Required)

Therapist Match Form

Eating Disorder Support

Before submitting this form please review the following information:

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)

Before submitting this form please review the following information:

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 Support

Before submitting this form please review the following information:

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 Assessment

Before submitting this form please review the following information:

Thank you for your interest in TPWG. We greatly appreciate your trust and hope to be able to support you in achieving your goals.

Psychoeducational Assessment

Before submitting this form please review the following information:

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 Training

Thank you for your interest in TPWG. We look forward to connecting with you soon!