CMHRT Prospective Client Information Form

**Please note that our Centre is temporarily closed for our in-person individual therapy services due to the COVID-19 pandemic. We are offering telepsychology by video services for adults, children, and youth residing in Ontario. There are wait lists for all telepsychology services. We are now at capacity for the provision of psychoeducational assessments for adults and children/youth for this academic year. We have closed our wait list for psychoeducational assessments and hope to re-open the wait list for new referrals in May 2022. **

Please fill out the following information and we will contact you within three business days for further information.

Information and privacy: questions regarding the collection of information on this form can be directed to the form administrator.

Please provide your first name/given name.
Please provide your last name/surname.
Date of birth * (required)
Please provide a phone number where you can be contacted. (Please use the format XXX-XXX-XXXX, and include an extension if applicable.)
What is the best way to reach you? * (required)
Is it okay to leave a message? * (required)
Who are you requesting services for? * (required)
Child's birth date * (required)