Service Request

Please complete this questionnaire to request psychotherapy, sex therapy, psychological or neuropsychological assessment services.

Please note that your request could be added to a waiting list depending on the problem and the availability of our professionals.

When availability becomes available, a receptionist will contact you to schedule a first appointment.

Identification

I am looking for psychological services for

An adult

18 years old and over

A teenager

14 to 17 years old

A child

13 years old and under

A couple

Two adults

Warning: if your browser has automatically filled in the first and last name fields, make sure that it is those of the person to whom the services will be offered.

First name of your partner

Last name of your partner

First name of the mother

Last name of the mother

First name of the father

Last name of the father

Date of birth of your partner

I prefer the consultation to take place this way

In person

Consultation will take place at Y2 Consulting Psychologists.

Remotely

Consultation will take place by video call.

No preference

Consultation will take place in person or remotely.

Main reason for consultation

Other reason for consultation (optional)

Details (optional)

This information will be used by a receptionist to select a professional for the consultation.

Communication

Personal email address

Home phone

Work phone

Cell phone

Preferred communication method

Preferred communication language

Province of residence

Billing

Please note: keep in mind that our fees are tax-free and are repayable, in whole or in part, by various insurance plans. However, we strongly advise you to consult your insurance plan to understand the inclusions and exclusions of your coverage. Regardless of your coverage, however, you must pay after each session. A receipt will then be issued which will allow you to claim a refund from your insurance company. Please note that we need a letter from your employer/payer in which he confirms that he will pay.

Who will pay for the services?

Please note that if your employer will pay the fees for your psychological services, we will need a letter confirming that he will pay, and other financial details (eg: maximum number of session, maximum budget).

Organization

Contact person

Address

City

Province

Postal code

Availabilities

Do you want us to offer you an appointment as soon as a time slot becomes available (recommended) or do you want to specify your availabilities (maybe longer)?

Additional details you would like to mention about availabilities

Reference

Referred by

Physician's name

Is this physician your family physician?

Yes

Third party

Is there a third party, other than private insurance, involved in your claim?

Details

Please provide as much detail as possible.

Send service request

Click on the Submit button to send your request.

Warning: you will not be able to change your request afterward.

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
AM
PM
Evening