Initial Inquiry Form - Psychotherapy Services

Full Name

Preferred Name

Phone Number

Preferred Method of Contact

Phone Text Email

Reason for Inquiry (Brief summary only)

Therapist Preference
(Please indicate any gender or specialization preferences. Write in “N/A” if not applicable.)

Referral Source

Please review the following information and provide your consent:

While we take all reasonable steps to protect your privacy, please be aware that electronic communications (e.g., email and text messages) may not be fully secure, and there is a risk that your personal information could be accessed by unauthorized individuals. By consenting to electronic communication, you acknowledge and accept this potential risk.

I understand that Percepta Leadership and/or its associates may use the communication methods I have selected above to contact me. I also understand that Percepta Leadership may share information from my initial inquiry with a Psychotherapist associate(s) for the purpose of coordinating an initial consultation.

I acknowledge that I have been informed of the potential privacy risks associated with electronic communication, and I consent to the use of these methods. I also understand that I may withdraw my consent at any time by notifying my service provider in writing.

Please provide consent

I consent to be contacted as indicated above and to my information being shared with the appropriate associate(s).
Selecting this checkbox constitutes my electronic signature and full consent to the above terms under applicable Canadian law (PIPEDA), with the same legal effect as a handwritten signature.

I do not consent to the above and prefer an alternative arrangement (please specify):

Legal Name

Date