Request For Service Please complete the form below to make a confidential request for service. Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Client InformationName *FirstLastDate of Birth *City *Contact Phone *Alternate PhoneEmail *If you are seeking therapy for a child, please provide their name and date of birth below. Child's NameFirstLastChild's Date of BirthTherapy PreferencesTherapist PreferenceIf you have a therapist preference, please indicate above. If you're unsure at this point, feel free to skip this question. Preferred Therapist Gender *FemaleMaleNon-BinaryOtherNo PreferencePreferred Session Format *In-PersonVirtualNo PreferencePreferred Days of the Week *MondayTuesdayWednesdayThursdayFridaySaturdayNo preferenceTo maximize chances of pairing you with your preferred therapist, please select ALL of the days that you are available.Preferred Time of Day *DaytimeEveningNo PreferenceArea(s) of Focus for Therapy *This field is optional. However, providing an area of focus can help us identify an appropriate therapist(s) for you.Insurance/Benefits InformationRGA & The Space Within has partnered with the following community businesses to provide employee assistance program (EAP) benefits. If you or a family member works for one of these businesses, please indicate below so we can verify benefit eligibility. Employer (if other, add employer name below)FIO AutomotiveFAG/Schaeffler Canada IncPerth Community Futures Development CorporationWallenstein Feed & SupplyEmployee NumberInsurance/Benefit Plan Coverage *Registered PsychologistRegistered PsychotherapistRegistered Social WorkerNo Insurance BenefitsCertified Mental Health CounsellorIf you're planning to claim your sessions with your health benefits provider, please verify the types of practitioners covered under your plan.Submit
