Registered client?
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Location:
Virtual / In Person at Beaches Office
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Service:
Homewood Health
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Date/time:
Thu, May 23 at 3:15 PM
(EDT)
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Please note, a professional hour is
50
minutes
. I require the last 10 minutes of the hour to:
Schedule your next appointment
Issue you a receipt
Make clinical notes about the session and your treatment plan
Record the goals for the next appointment
Thank you !
Please do not submit any Protected Health Information (PHI)
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First name
*
Last name
*
Email
*
Phone
*
How did you hear about us?
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Through Your Website
My Family Doctor
LUMINO Health (Sunlife)
I'm a Previous Client
Psychology Today Website
Google Search
Dr. Dan Dalton
Friend / Relative
Beach Metro News
Harbourfront Psychotherapy Website
Beaches Psychotherapy Website
My EAP
Yelp
Other
Extended Health Care Provider
*
Enter N/A if you are NOT using Extended Health benefits
N/A
Blue Cross
Blue Shield
Des Jardins
Manulife
Greenshield
Liberty Health
Sun life
Other not listed above
If an EAP has referred you, which one?
*
Enter N/A UNLESS your EAP has referred you.
N/A
Homewood
Inkblot
FSEAP
What is your reason for seeking counselling today?
*
Confidential: This will only be seen by your therapist.
Sex Therapy
Sexual Assault/ Rape/ Incest
Abuse (Physical/Sexual/Emotional)
Couples Counselling
Separation & Divorce Counselling
Anxiety and/or Panic Attacks
Depression
P.T.S.D.
Stress (Work or Personal)
Work Related Problems
Relationship Problems [any]
Self-Esteem / Confidence
Career Counselling
Family Conflict / Counselling
Work/Life/Balance
Youth Work
Other Counselling
Prefer to Discuss Privately
* required field