Get startedFill out the form provided below, and we will get back to you shortly. Client Name * First Name Last Name Parent/Guardian Name (if applicable) First Name Last Name Age * Gender Phone * (###) ### #### Email * Juniper has specializations and training in the following areas of mental health. Please indicate which concerns are the most important for you to focus on in therapy: * General Anxiety Social Anxiety Health Anxiety Panic Disorder Obsessive Compulsive Disorder Skin picking/Hair pulling Specific phobia Depression or low mood Motivation Self-harm Anger or aggression Perfectionism Eating concerns/Body image concerns Self-esteem Life stress Life purpose or meaning Chronic health/Chronic pain Trauma Sexual Trauma Gender/Sexuality Grief Parent support If you like, please provide more information about how these concerns are impacting your well-being: If you are hoping to work on a concern that is not listed above, please tell us more. We will check with our team to ensure we have the specialized care you deserve. Please indicate your preference for therapy: * In-person Video/Phone Mix of both Where would you like to receive services? * Kanata Location Manotick Location Do you have a preferene? Female therapist Male therapist No preference Do you have private insurance that covers mental health services? This information helps us to ensure you receive the best possible care with optimal coverage. * Yes No If yes, which services are covered by your insurance provider? (select all that apply) * Registered Social Worker Registered Psychotherapist Unsure Do you require any accomodations? Please provide us with details about how we may support you: Thank you!
