Book Now - MindKey Health

New Booking Request

Due to an influx of booking requests, expect up to one week of wait time following your submission to be contacted by a clinic representative.

Fill in the boxes below and a representative will connect with you to complete the booking.
Which service do you want to make a booking for?*
Which location do you want to make a booking at?*
Who is this booking for?*
If completing the form for yourself, please provide your information. If completing the form for someone else/ your child, please provide their information.
Informed Consent*
We practice Informed Consent which requires the legal parent(s) or guardian(s) to authorize Consent for Services. Are you an intact family or co-parenting at separate addresses?
Parent/Guardian Name(s)*
First Name Last Name

Use the (+) button to add another row.
Name*
First Last
Email Address*
Phone Number*
Address*
Street Address City Province Postal Code
Child's Name*
First Last
Date of Birth*

Year
Month
Day

Provide your date of birth if this booking is for yourself, otherwise provide the date of birth for the person this booking is for.
What are your main concerns?*
List your top three.
#1 - #2 - #3 -
Do you have a preferred counsellor from our list of available staff?
Preferences will be honoured if possible, but are not guaranteed.
Are you open/willing to seeing an intern if your preferred counsellor is unavailable?*
Preferences will be honoured if possible, but are not guaranteed.
Please indicate counselling preferences:
- in-person appointments
- virtual appointments
- female counsellor
- male counsellor
- no preference on counsellor
- needing after school times
School Grade
Name of the school attending
Is your child Francophone or enrolled in French Immersion?*
Is this a reassessment?*
What year was the previous assessment conducted?*
Where was the previous assessment conducted?*
Please specify if the previous assessment was conducted through one of our offices or somewhere else.
Would you like to be added to a cancellation list?
If assessment appointments at your selected location open in the time before your intake, we will contact you to offer the availability. Cancellations are first come, first serve. We will contact the cancellation list in order of submission; if the assessment works for you, please let us know ASAP. If you cannot take a cancellation availability, you will remain on the cancellation list.
Will this be covered by a third-party payer?*
- No
- Yes
Third-party payers may include: Autism Funding Unit, Jordan's Principle, Variety, SelfDesign, Heritage Christian, Regent Christian, Kleos, etc. This does not refer to your extended health benefits or medical insurance as we do not direct bill.
Do you have any notes or comments?
Anything you would like to pass along regarding the assessment? If you called the office first to discuss please make note of the phone call.
Email
This field is for validation purposes and should be left unchanged.

First Name	Last Name

New Booking Request

Seeking Counselling Support?