Dear Applicant,
Thank you for contacting the TICP Referral Service. After completing the enclosed therapy application form, please mail it along with a cheque payable to TICP for $25.00 to the address listed below. This fee is charged to offset administrative costs. You can also complete and submit your application online. We assure you that your application will receive careful consideration and will be held in the strictest of confidence. We will contact you promptly with the name of a therapist who is available to meet with you to assess your needs and provide the treatment you require. Our therapists are not covered by OHIP and therefore the fee for psychotherapy sessions is discussed and determined during your first treatment session. We hope it will be possible for us to help you. Should we be unable to provide the services you need, every effort will be made to connect you with other agencies or individuals who may be able to do so.
Thank you again for using our services.
Sincerely,
Kadri-Ann Laar, Ph.D, C.Psych., Chair
99 Post Rd., Toronto, ON M3B 1J3
E-mail: laarka@sympatico.ca
Naomi Stein, MA
TICP Referral Service Committee

Therapy Application

First name *
Initial
Last name *
Date of Birth
Date of Application
Home Address
Business Address
Home Tel
Business Tel
May we leave a telephone message for you at your home? YesNo
May we leave a telephone message for you at your business? YesNo
Preferred mailing address? HomeBusiness
Occupation

By whom were you referred?

Name
Address
Phone number
Do you require wheelchair access? YesNo
Are you able to schedule sessions during regular work hours? YesNo
If not, please state times that would be possible to schedule sessions:
Type of treatment you are seeking: UnknownPsychoanalysis (four times a week)Psychotherapy (one to three times a week)
Do you have any privately paid health insurance? YesNo
If yes, please indicate whether it covers psychotherapy services. YesNo
Maximum dollar amount covered per year:

Please check all the reasons you are seeking psychotherapy. You may check more than one

Anxiety
Bereavement
Confusion about self-image, goals etc.
Decreased performance at work, home, or school
Depression
Health status of myself, or someone I care about
Memory problems
Relationship problems
Problems with alcohol or drug use
Planning the future
Concerns about sexual abuse
Concerns about physical abuse
Aftermath of a trauma
Concerns about anger management
Concerns about the amount of stress you are experiencing
Thoughts or attempts at suicide
Concerns about sexual performance or enjoyment
Other (Specify)
Please indicate the main reason ---- Anxiety Bereavement Confusion about self-image, goals etc. Decreased performance at work, home, or school Depression Health status of myself, or someone I care about Memory problems Relationship problems Problems with alcohol or drug use Planning the future Concerns about sexual abuse Concerns about physical abuse Aftermath of a trauma Concerns about anger management Concerns about the amount of stress you are experiencing Thoughts or attempts at suicide Concerns about sexual performance or enjoyment
Have you been in psychotherapy previously? ---- No Yes (once) Yes (two to four times) Yes (more than four times)
If yes, please state when you were last in therapy
What was the longest time in any one therapy?
Frequency of sessions per week for your longest therapy:
Have you ever been hospitalized for emotional or mental problems? YesNo
If yes, number of hospitalizations?
Date of most recent hospitalization?
Duration of most recent hospitalization

Please state as fully as you can what your present difficulties are, how long they have existed, and your reasons for seeking treatment at this time. (Use as much space as needed):