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User Survey and RSA Form

Our site requests information from users via a User Survey and a Referral Service Application form. Participation in the Survey or form is completely voluntary and the user therefore has a choice whether or not to disclose personal information. The requested information includes contact information (such as name and address), and demographic information.

Contact information will be used to get in touch with those who have filled out the RSA form. Survey information will be used for purposes of monitoring and improving the use and satisfaction of this site. Site visitors’ personally identifiable information is not shared with third parties. We do not use visitors’ personally identifiable information for any secondary purposes.

Treatment Application Form

Dear Applicant,
thank you for contacting the TICP Referral Service. After completing the therapy application form, please mail it to the address listed below.

You can also complete and submit your application online by clicking here. Or, you may choose to email your application, as described below.

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.

Kadri-Ann Laar, Ph.D, C.Psych., Co-Chair
99 Post Rd., Toronto, ON M3B 1J3
Deborah Levine, Ph.D., Co-Chair
TICP Referral Service Committee

Please click on the button below to download an application form for treatment referral.

Completed applications may be mailed to the address listed above. If you wish, completed applications may also be emailed in strict confidentiality to Kadri-Ann Laar, Ph.D. and Co-chair of the TICP Referral Service at

Alternatively, you may choose to complete an ONLINE APPLICATION FORMClick here to apply online.