Secure Appointment Request Form

Name Phone Number Can we leave a message at this number?

Yes

Once the referral is assigned, you will be contacted directly by the therapist.

Please provide a brief description of the problem Are you requesting a specific therapist? What service are you interested in?

If the client is a minor...

Pleases provide their name How old are they?

Do you have any preferences/requests regarding appointment times? (Note: Some therapists are available for evening and weekend appointments.) How did you hear about our agency?

I am aware that there are fees associated with the services requested

During the pandemic, therapists continue to work with clients regularly and are available for new referrals via telepsychology.

Connect with Us

General questions for our administrative staff can by made by calling 780 439-5683 (ext 0 ) or via the Contact Us link. Questions or referrals can also be made directly to a professional by calling the number listed on their profile page.