Request for Service – Oakhill Counselling & Mediation Services

Date / Time *//

Name *

First

Last

Address

City

Phone Number *

Can we leave a message at this number? *

Yes
No

Email

Can we send emails to this email address?

Yes
No

Please note, our appointment system sends reminder emails and notifications to the email provided. If you provide an email address, please know that we will assume you are giving consent to receive these emails. If at anytime you wish to end this service, please call our office to let us know.

Are you contacting us on someone else's behalf? *

Yes
No

If the person is over the age of majority, we require the person to contact us directly to set up service unless you have a power of attorney. Otherwise, they can provide consent at that time for another person to make appointments or disclose information to other parties if they wish.

Type of Service Requested *

*Some insurance plans will over cover registered psychologists. If you are unsure whether you need to see a registered psychologist or not, please consult with your human resource department or contact your insurance provider.

Who is the service for? *

Will others be involved in the service with you? *

Yes
No

If yes, please provide first names and ages

If this is related to supervised visitation or mediation, please provide the name of the other party. If this is regarding couples or family counselling or counselling for someone under 19, please provide their name(s) and age(s).

Do you have an Employee Assistance Program? *

Yes
No
Unsure

Please note, if you have an Employee Assistance Program (EAP/EFAP), they require you to call them directly to open a file to receive services. Once open, you can request Oakhill Counselling and then we will be in contact to schedule your first appointment when we receive the referral from the EAP service. If you are unsure if your employer has an EAP service, contact your Human Resources office or call the Oakhill office at 1-800-665-9033 and we may be able to direct you accordingly.

Name of employer

Service details/preferences

Please be aware that we cannot guarantee to meet all of your specific criteria but will do our very best and review the available options with you to best meet your service needs.

What is/are the issues you'd like to talk about (in a word or two) *

Do you have a preference for male or female counsellor?

Male
Female
No preference

Preferred appointment day?

Preferred appointment time

Morning
Afternoon
Evening
No preference

Preferred Location

Do you have any special requests? (LGBTQ, ethnicity, languages spoken, etc)

How did you hear about Oakhill Counselling? *