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- Contact Details
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Donate

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Online Application

Dear Applicant,

Thank you for contacting the TICP Referral Service. After completing the online therapy application form, please click submit.

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.

The fee for psychotherapy sessions will be 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

Treatment Application Form

Complete the application for referral form below (online), and click submit when finished. Your form will automatically be forwarded to the TICP Referral Service.

Url

Fields marked with an * are required

First Name *

Last Name *

Email Address *

Date Of Birth

Date Of Application

Home Address

Business Address

Home Phone

Business Phone

May we leave a telephone message for you at your home?

Yes

No

May we leave a telephone message for you at your business?

Yes

No

Preferred mailing address?

Occupation

By whom were you referred? (Name)

Phone

Address

Do you require wheelchair access?

Yes

No

Are you able to schedule sessions during regular work hours?

Yes

No

If not, please state times that would be possible to schedule session:

Type of treatment you are seeking:

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

Have you been in psychotherapy previously?

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?

Yes

No

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:

(Anti-Spam Question) What is 2 + 3? * *

About TICP

TICP Office & Community Clinic
427 Vaughan Rd., Toronto, ON, M6C 2P1

Phone: 416-288-8060
Fax: 1-866-403-3066

TICP is registered as a Private Career College with the Ontario Ministry of Colleges and Universities, Reg# 203867, and as such operates under the regulations outlined in the Private Career Colleges Act, 2005.

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