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Thank you for your interest in CBT Associates.
Please complete the following Intake Form to get started with us.
Note: If you are completing the form on behalf of someone else please fill in details of the prospective client wherever relevant.
Please indicate if you are completing this form for yourself *
*
Yes
No
If No, please specify if you are the Mother, Father, Sibling, Health Care Provider, etc. of the prospective client.
Name (of client)
*
First
Last
Email
*
Phone
*
Preferred method of communication
Email
Phone
No preference
Gender (of client)
*
Female
Male
Non-Binary
Prefer not to say
Date of Birth (of client)
*
MM slash DD slash YYYY
Type of Therapy
*
Child/Adolescent Therapy
Couples Therapy
Family Therapy
Individual Therapy
Location Preference
*
Virtual Only
Downtown
North York
Additional Location Preference
What is your availability for therapy sessions? (identify all that apply: Morning, Afternoon, Evening, Weekends) *
*
Our therapy services are not covered by OHIP. Will you be using Private Health Insurance?
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Yes
No
Please identify what services are covered by your private health insurance. (Psychologist, Registered Psychotherapist, Registered Social Worker, N/A, Unsure). ** If you are unsure, please follow up with your insurance provider and let us know as soon as possible. This information is important to process your intake. Reach out to info@cbtassociates.com or 416-363-4228
*
Here at CBT Associates we have multiple types of clinicians. Their rates differ based on qualifications and experience. Do you have a preference for the clinician type or rate? The price breakdown is as follows: 1) Registered Psychologists from $225 to $265; 2) Registered Psychotherapists from $160 to $235; 3) Registered Social Workers from $160 to $200; and 4) MA Level Associates/Psychology Residents from $150 to $225
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Please describe the main concerns or focus for therapy. Consider including information on the following: (1) Any known mental health diagnoses or outcomes of other assessments (2) Concerns about alcohol, drug abuse, or overuse of non-prescribed drugs (3) Previous experience with therapy, (4) Self-harm or safety concerns and (5) Overall goals for treatment. Feel free to include additional information to help us make the right match for services.
Gender Preference of Clinician
*
Female
Female Preferred (Male OK)
Male
Male Preferred (Female OK)
No Preference
If you are looking to work with a specific clinician, please list their name here.
Are you or your client signing up as part of an Institutional Program with CBT Associates?
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No
If Yes, please enter Institution Code
By checking this box, I give consent to be contacted or have obtained consent for client to be contacted. Please note this form will not be reviewed immediately. CBT Associates Intake team will review all inquiries but we are not an emergency or crisis service. In the event of an emergency, you should call 911 or go to the nearest hospital emergency room. If you are experiencing a crisis, please call 1-833-456-4566 toll free, 24/7 or visit www.crisisservicescanada.ca for support.
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Adults
Adult Assessment
Adult Treatment
Problems Addressed
Children & Adolescents
Treatment for Children & Adolescents
Third-Party Referrals & Services
Virtual Therapy
Virtual Therapy with CBTA
Live Sessions with MindBeacon
About Us
About CBT Associates
The CBT Approach
The CBT Associates Team
Rates & Fees
Train With Us
Supervised Practice
Clinical Psychology Residency Program
Join Our Team
Contact & Locations
