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Individual & Couples Intake Salesforce

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    If you want therapy, please go BACK
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    Go BACK below if this is not what you're looking for.
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    As our forms are not monitored 24 hours a day or all days of the week, if you or someone you know is in crisis or at risk of serious harm towards yourself or others, call 911 or go to an emergency room.
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    For clients 16 years or younger, Layla requires consent of parent or guardian
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    For clients 16 years or younger, Layla requires consent of parent or guardian
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    Please select
    • Please select
    • ADHD (strategies to manage)
    • Anger management
    • Anxiety (incl. panic, GAD, and social)
    • Behavioral Addiction
    • Bipolar (Type I or II)
    • BPD or related symptoms
    • Coping with chronic pain or illness
    • Coping with concussion or ABI
    • Eating disorder
    • Emotional eating/other eating challenges
    • Emotion regulation
    • Depression, sadness, or low mood
    • Dissociation
    • Family conflict
    • Grief or loss
    • Life transitions/uncertainty
    • OCD-related symptoms
    • Parenting
    • Personality disorder other than BPD
    • Phobia(s)
    • Pre- or Post-Natal challenges
    • Psychosis
    • Relationship challenges
    • Self-esteem
    • Self-exploration
    • Sexual abuse/assault (including childhood sexual abuse)
    • Sexual or gender identity
    • Sexual dysfunction
    • Skin-picking or hair-pulling
    • Sleep concerns
    • Stress/burnout
    • Substance use or addiction
    • Trauma (single-incident)
    • Trauma (multiple incident or ongoing)
    • Work or school issues
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    Please select
    • Please select
    • Improve Communication
    • Conflict Resolution
    • Parenting Skills
    • Problem Solving
    • More intimacy (emotional)
    • More intimacy (sexual)
    • More quality time together
    • Amicable separation
    • Resolve individual issues
    • More autonomy
    • More respect/understanding
    • Power and control issues
    • More hobbies
    • More social contracts
    • More sharing of the chores
    • Help for children's behaviour
    • Court-mandated
    • Other
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    Please add any additional concerns here that may be important to discuss with your therapist but are not your main reason for seeking therapy. You don't need to re-select any items mentioned in the previous question. If you don’t have anything further to add, feel free to skip this question
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    Select all that apply
    Please select
    • ADHD (strategies to manage)
    • Aging
    • Anger management
    • Anxiety (incl. panic, GAD, and social)
    • Behavioral Addiction
    • BPD or related symptoms
    • Coping with chronic pain or illness
    • Coping with concussion or ABI
    • Court-mandated
    • Eating disorder
    • Emotional eating/other eating challenges
    • Emotion regulation
    • Depression, sadness, or low mood
    • Dissociation
    • Family conflict
    • Fertility Issues
    • Grief or loss
    • Impacts of racism or discrimination
    • Imposter Syndrome
    • Immigration-related life challenges
    • Life transitions/uncertainty
    • OCD-related symptoms
    • Personality disorder other than BPD
    • Phobia(s)
    • Pre- or Post-Natal challenges
    • Psychosis
    • Relationship challenges
    • Intimate partner abuse
    • Self-esteem
    • Self-exploration
    • Sexual or gender identity
    • Sexual dysfunction
    • Skin-picking or hair-pulling
    • Sleep concerns
    • Stress/burnout
    • Substance use or addiction
    • Trauma (single-incident)
    • Trauma (multiple incident or ongoing)
    • Work or school issues
    • Other
    • Attachment Disorders
    • Parenting
    • Perfectionism
    • School-related anxiety/Avoidance
    • Sport-related / Athletes
    • Women's Issues (Hormonal)
    • Young Adult
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    Please select
    • Improve Communication
    • Conflict Resolution
    • Parenting Skills
    • Problem Solving
    • More intimacy (emotional)
    • More intimacy (sexual)
    • More quality time together
    • Amicable separation
    • Resolve individual issues
    • More autonomy
    • More respect/understanding
    • Power and control issues
    • More hobbies
    • More social contracts
    • More sharing of the chores
    • Help for children's behaviour
    • Court-mandated
    • Other
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    Optional, select up to 3
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    Skip if not applicable
    Click to select
    • ADHD (strategies to manage)
    • Adjustment disorder
    • Agoraphobia
    • Anorexia Nervosa
    • Antisocial personality disorder
    • Anxiety (Unspecified)
    • Any diagnosis related to neglect or abuse
    • Any Psychotic disorder
    • Any Sexual Disorder
    • Any Sleep Disorder (Incl. Insomnia)
    • Any Substance Use Disorder
    • Autism spectrum disorder
    • Binge-eating disorder
    • Bipolar Disorder (Type I or II)
    • Body dysmorphic disorder
    • Borderline Personality Disorder
    • Bulimia Nervosa
    • Conduct disorder
    • Delusional disorder
    • Depression (Unspecified)
    • Dissociative identity disorder
    • Enuresis
    • Gambling disorder
    • Gender dysphoria
    • Generalized Anxiety
    • Hoarding disorder
    • Health anxiety
    • Intellectual disability
    • Intermittent explosive disorder
    • Kleptomania
    • Major Depressive Disorder
    • Narcissistic personality disorder
    • OCD
    • Oppositional defiant disorder
    • Overweight or obesity
    • Panic Disorder/Panic attacks
    • PDD (dysthymia)
    • Premenstrual dysphoric disorder
    • PTSD
    • Pyromania
    • Reactive attachment disorder
    • Separation anxiety disorder
    • Skin-Picking or Hair-Pulling
    • Social Anxiety
    • Specific learning disorder
    • Specific phobia
    • Tourette’s disorder
    • Unspecified personality disorder
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    Select all that apply
    Click to select
    • Single
    • Dating
    • Living together
    • Common law
    • Married
    • Divorced
    • Separated
    • Living apart
    • Widowed
    • Not sure
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    0 being poor and 10 being exceptional
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    1 being poor and 10 being exceptional
    Please select a number between 1 and 10
    • Please select a number between 1 and 10
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    1 being poor and 10 being exceptional
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    Select all that apply
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    Briefly elaborate on the nature of the problem (e.g. substance, reason for concern, etc.). Skip if not applicable
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    If so, in what way?
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    Couples counseling is generally not recommended when abuse is present in a relationship.

    Couples counseling, while effective for many issues, cannot mend the unequal power structure that is present in an abusive relationship, thus may result in further harm for parties involved.

    Therefore, individual counseling may be suggested on your call and we suggest completing an individual intake form instead of continuing with the couples form.

    If you believe intimate partner violence is not present in your relationship, you may continue with this intake form to explore couples counseling options. 

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    We will directly follow up with the individual who has indicated yes to feeling afraid of the other partner
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    0 being poor and 10 being exceptional
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    1 being poor and 10 being exceptional
    Please select a number between 1 and 10
    • Please select a number between 1 and 10
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    Generally, couples counselling begins weekly or bi-weekly and may taper down, but it depends on the therapist and clients’ specific case
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    If you or someone you know is in crisis or at risk of serious harm towards yourself or others, call 911 or go to an emergency room
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    In-Person Availability

    Similar to the broader sector, we have lower in-person therapist availability. Depending on your overall needs, we might not be able to find the right therapist for you who is also offering in-person sessions. Video or phone sessions can be a great place to start and research shows high effectiveness in therapy.

    Your Care Coordinator would be happy to discuss options with you to find the best fit.

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    Our in-person therapists are location across GTA and surrounding areas. Go back to choose remote only options
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    • Toronto - East End (E of Sherbourne)
    • Toronto - West End (W of Bathurst)
    • Toronto - Midtown (N of Davenport)
    • Toronto - Downtown (S of Davenport)
    • Toronto - North West
    • Etobicoke
    • North York
    • Scarborough (E of Victoria Park)
    • Durham Region
    • Halton Region
    • Peel Region
    • Hamilton
    • Markham
    • Richmond Hill
    • Newmarket
    • Vaughan (includes Woodbridge)
    • Kitchener/Waterloo/Guelph
    • Barrie
    • Ottawa
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    • 10 pm
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    All our therapists are licensed to conduct Psychotherapy in their jurisdiction. We currently have only a limited number of psychologists in Ontario and Nova Scotia. To learn more about our pricing please click here.
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    While we do our best to match on as many factors as we can, we cannot always match on all preferences. Your Care Coordinator will discuss options with you on your intro call.
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    Skip if not, or not sure
    Click to select
    • Click to select
    • ACT
    • Accelerated Resolution Therapy
    • CBT-Informed
    • CBT-Structured
    • DBT-Informed
    • DBT-Structured
    • EMDR
    • EFT
    • Mindfulness
    • Psychodynamic
    • Anti-Oppressive Practice
    • Short-Term Solution-Focused
    • Narrative Therapy
    • Somatic
    • Hypnotherapy
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    We strive to be inclusive of all equity-seeking groups in Canada. If your racial identity is not represented in the options provided, please do not hesitate to contact us at contact@layla.care
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    We strive to provide an inclusive client experience. Our country and region list, based on SCCAI-2019 and ISO 3166, reflects no endorsement or opinions on specific names. Canada & North America are excluded from these lists as all of our therapists are Canadian Residents.
    Please Select
    • Åland Islands
    • Albania
    • Algeria
    • American Samoa
    • Andorra
    • Angola
    • Anguilla
    • Antarctica
    • Antigua and Barbuda
    • Argentina
    • Armenia
    • Armenia
    • Aruba
    • Australia
    • Austria
    • Azerbaijan
    • Azerbaijan
    • Bahamas (the)
    • Bahrain
    • Bangladesh
    • Barbados
    • Belarus
    • Belgium
    • Belize
    • Benin
    • Bermuda
    • Bhutan
    • Bolivia / Bolivia (Plurinational State of)
    • Bonaire, Sint Eustatius and Saba
    • Bosnia and Herzegovina
    • Botswana
    • Bouvet Island
    • Brazil
    • British Indian Ocean Territory (the)
    • Brunei Darussalam
    • Bulgaria
    • Burkina Faso
    • Burundi
    • Cabo Verde
    • Cambodia
    • Cameroon
    • Cayman Islands (the)
    • Central African Republic (the)
    • Chad
    • Chile
    • China
    • Christmas Island
    • Cocos (Keeling) Islands (the)
    • Colombia
    • Comoros (the)
    • Congo (the Democratic Republic of the)
    • Congo (the) / Congo, Republic of the
    • Cook Islands (the)
    • Costa Rica
    • Côte d'Ivoire
    • Croatia
    • Cuba
    • Curaçao
    • Cyprus
    • Czechia
    • Denmark
    • Djibouti
    • Dominica
    • Dominican Republic (the)
    • Ecuador
    • Egypt
    • El Salvador
    • Equatorial Guinea
    • Eritrea
    • Estonia
    • Eswatini
    • Ethiopia
    • Falkland Islands (the) [Malvinas]
    • Faroe Islands (the)
    • Fiji
    • Finland
    • France
    • French Guiana
    • French Polynesia
    • French Southern Territories (the)
    • Gabon
    • Gambia (the)
    • Georgia
    • Germany
    • Ghana
    • Gibraltar
    • Greece
    • Greenland
    • Grenada
    • Guadeloupe
    • Guam
    • Guatemala
    • Guernsey
    • Guinea
    • Guinea-Bissau
    • Guyana
    • Haiti
    • Heard Island and McDonald Islands (the)
    • Holy See (the)/Holy See (Vatican City State)
    • Honduras
    • Hong Kong
    • Hungary
    • Iceland
    • India
    • Indonesia
    • Iran / Iran (Islamic Republic of)
    • Iraq
    • Ireland
    • Isle of Man
    • Israel
    • Italy
    • Jamaica
    • Japan
    • Jersey
    • Jordan
    • Kazakhstan
    • Kazakhstan
    • Kenya
    • Kiribati
    • Kosovo
    • Kuwait
    • Kyrgyzstan
    • Lao People's Democratic Republic (the)
    • Latvia
    • Lebanon
    • Lesotho
    • Liberia
    • Libya
    • Liechtenstein
    • Lithuania
    • Luxembourg
    • Macao
    • Madagascar
    • Malawi
    • Malaysia
    • Maldives
    • Mali
    • Malta
    • Marshall Islands (the)
    • Martinique
    • Mauritania
    • Mauritius
    • Mayotte
    • Mexico
    • Micronesia (Federated States of)
    • Moldova (the Republic of)
    • Monaco
    • Mongolia
    • Montenegro
    • Montserrat
    • Morocco
    • Mozambique
    • Myanmar
    • Namibia
    • Nauru
    • Nepal
    • Netherlands / Netherlands (Kingdom of the)
    • New Caledonia
    • New Zealand
    • Nicaragua
    • Niger (the)
    • Nigeria
    • Niue
    • Norfolk Island
    • North Korea / Korea (the Democratic People's Republic of)
    • North Macedonia
    • Northern Mariana Islands (the)
    • Norway
    • Oman
    • Pakistan
    • Palau
    • Palestine
    • Panama
    • Papua New Guinea
    • Paraguay
    • Peru
    • Philippines (the)
    • Pitcairn
    • Poland
    • Portugal
    • Puerto Rico
    • Qatar
    • Réunion
    • Romania
    • Russian Federation (the)
    • Rwanda
    • Saint Barthélemy
    • Saint Helena, Ascension and Tristan da Cunha
    • Saint Kitts and Nevis
    • Saint Lucia
    • Saint Martin (French part)
    • Saint Pierre and Miquelon
    • Saint Vincent and the Grenadines
    • Samoa
    • San Marino
    • Sao Tome and Principe
    • Sark
    • Saudi Arabia
    • Senegal
    • Serbia
    • Seychelles
    • Sierra Leone
    • Singapore
    • Slovakia
    • Slovenia
    • Solomon Islands
    • Somalia
    • South Africa / South Africa, Republic of
    • South Korea / Korea (the Republic of)
    • South Sudan
    • Spain
    • Sri Lanka
    • Sudan (the)
    • Suriname
    • Svalbard and Jan Mayen
    • Sweden
    • Switzerland
    • Syrian Arab Republic (the)
    • Taiwan
    • Taiwan (Province of China)
    • Tajikistan
    • Tanzania / Tanzania, the United Republic of
    • Thailand
    • Timor-Leste
    • Togo
    • Tokelau
    • Tonga
    • Trinidad and Tobago
    • Tunisia
    • Türkiye
    • Turkmenistan
    • Turks and Caicos Islands (the)
    • Tuvalu
    • Uganda
    • Ukraine
    • United Arab Emirates (the)
    • United Kingdom / United Kingdom of Great Britain and Northern Ireland (the)
    • United States Minor Outlying Islands (the)
    • United States of America (the)
    • Uruguay
    • Uzbekistan
    • Vanuatu
    • Venezuela
    • Venezuela (Bolivarian Republic of)
    • Viet Nam
    • Wallis and Futuna
    • West Bank and Gaza Strip
    • Western Sahara
    • Yemen
    • Zambia
    • Zimbabwe
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    Please select
    • Akan
    • Amharic
    • Arabic
    • Assamese
    • Athapaskan Languages
    • Awadhi
    • Azerbaijani
    • Balochi
    • Belarusian
    • Bengali
    • Bhojpuri
    • Bosnian
    • Burmese
    • Cantonese
    • Cebuano (Visayan)
    • Chewa
    • Chhattisgarhi
    • Chittagonian
    • Cree languages
    • Croatian
    • Czech
    • Deccan
    • Dhundhari
    • Dutch
    • Eastern Min (inc. Fuzhou dialect)
    • Filipino
    • French
    • Fula
    • Gan
    • German
    • Greek
    • Gujarati
    • Haitian Creole
    • Hakka
    • Haryanvi
    • Hausa
    • Hiligaynon/Ilonggo (Visayan)
    • Hindi
    • Hmong
    • Hungarian
    • Igbo
    • Ilocano
    • Indonesian
    • Innu/Montagnais
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    For example: works with a concern or diagnosis not previously listed
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    Please write your full name below. If you're a parent/guardian seeking support for a child, enter child's name.
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    For example, if your name is Amira, you could write it as "Ah-meer-ah
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    For example, if your name is Amira, you could write it as "Ah-meer-ah
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    By providing us with your partner's phone number they consent to receiving communications from the Layla Care team.
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    By providing us with your partner's email they consent to receiving communications from the Layla Care team.
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    This is also used for in-person therapy matching. Note that Layla's individual and couples counselling is only available to residents of ON, AB, BC, and NS at this time.
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    Availability in British Columbia

    Our provider availability in British Columbia is currently limited. You are still welcome to complete the intake form, and if we are unable to match you with a therapist after going through our process, we will provide alternative therapy options outside of Layla.

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    Include name(s), relationship to you, contact info (phone, email)
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    Provide name and email of person paying for sessions. By providing their name and email below, they consent to being contacted by Layla
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    Important Note Regarding Emergency Contacts
    Please be advised that your emergency contact should be someone other than your partner or spouse. This is to ensure that we can reach a different individual in case you and your partner are together during an emergency.

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    Please provide name, phone, email, and relationship to you The emergency contact will only be used if there is a concern for your safety. Your privacy is our priority, and we will handle this information with the utmost care.
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    A health and wellness professional is an expert who provides guidance and treatment to support physical, nutritional, or holistic well-being (i.e. chiropractor, physical therapist, dietician, massage therapist).
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    We will not reveal any information with your employer.
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    When you consent below, we will share an update on your therapist matching with your {howDid} including your name, date of birth, the name of your therapist, appointment information, and the Primary Concern you reported at intake.
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    When you consent below, we will share an update on your therapist matching with your Family Doctor including your name, date of birth, the name of your therapist, appointment information, and the Primary Concern you reported at intake.
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    Skip if not applicable
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    Name and area/region
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    Name and area/region
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    Layla's individual and couples counselling is only available to Ontario, Alberta, British Columbia and Nova Scotia residents at this time. All our therapists are licensed to provide psychotherapy in their jurisdictions through their respective regulatory colleges. Our therapists cannot diagnose or prescribe medication. Psychologists are only available for Alberta and British Columbia residents only. We have consistent pricing across all of our therapists and for all of our clients and thus cannot offer sliding scale services.
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    Layla's individual and couples counselling is only available to Ontario, Alberta, British Columbia and Nova Scotia residents at this time. All our therapists are licensed to provide psychotherapy in their jurisdictions through their respective regulatory colleges. Our therapists cannot diagnose or prescribe medication. We have consistent pricing across all of our therapists and for all of our clients and thus cannot offer sliding scale services.
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    We respect your right to privacy and follow all regulatory requirements for keeping your personal information private and secure. Limits to this confidentiality include any situation in which there are reasonable grounds for suspicion of harm to a child or serious imminent harm to yourself or others. In these situations, we have a right or obligation to break confidentiality for the safety of the person(s) at risk. For more information please review our complete Privacy Policy on www.layla.care/privacy-policy
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    We respect your right to privacy and follow all regulatory requirements for keeping your personal information private and secure. Limits to this confidentiality include any situation in which there are reasonable grounds for suspicion of harm to a child or serious imminent harm to yourself or others. In these situations, we have a right or obligation to break confidentiality for the safety of the person(s) at risk. For more information please review our complete Privacy Policy on www.layla.care/privacy-policy
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    A standard session length is 50 minutes and cost $165 ($185 for couples) including applicable taxes if any with a Registered Psychotherapist, Registered Counselling Therapist or Registered Social Worker, and $220 ($240 for couples) including applicable taxes if any with a Psychologist. You will be provided with a receipt for insurance. Layla reserves the right to change its prices with reasonable notice. A 24-hour cancellation policy applies. You will be responsible for full payment of appointments missed without 24 hour notice. Exceptions can be reasonably accommodated in the event of an unforeseen serious emergency. If you have 2 outstanding charges without having contacted us to explain why, you will not be able to book additional sessions until payment has been made or planned for.
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    A standard session length is 50 minutes and cost $165 ($185 for couples) including applicable taxes if any with a Registered Psychotherapist, Registered Counselling Therapist or Registered Social Worker, and $220 ($240 for couples) including applicable taxes if any with a Psychologist. You will be provided with a receipt for insurance. Layla reserves the right to change its prices with reasonable notice. A 24-hour cancellation policy applies. You will be responsible for full payment of appointments missed without 24 hour notice. Exceptions can be reasonably accommodated in the event of an unforeseen serious emergency. If you have 2 outstanding charges without having contacted us to explain why, you will not be able to book additional sessions until payment has been made or planned for.
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    Our therapists dedicate time and effort to ensure a personalized experience for you. To honour their commitment, we require clients to upload valid payment information to our app 26 hours before your first session. If payment information is not added by 26 hours before the session, we will proceed to cancel the appointment. Thank you for understanding, and for helping us create a respectful environment for both our clients and therapists.
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    Layla's intake call is free. Fees for subsequent therapy sessions apply. Layla's services are not covered by OHIP
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    Your therapist is a an independent practitioner contracted to Layla. You acknowledge that Layla Care Inc. itself is not providing treatment or other medical services to you. Layla makes suggested therapist matches to you based on the information provided by you and by them, and does not guarantee their ability to assist you. Therapists contacted to Layla are solely responsible – as independent providers - for the provision of professional health services as they deem appropriate. Any dispute between you and a therapist is strictly between you and such therapist Layla. You agree to indemnify and hold Layla, its directors, officers, employees, agents and shareholders, harmless from any claims, demands, losses, liabilities, and expenses arising in connection with: (i) your use of the Layla’s services, (ii) Healthcare services provided by an independent provider facilitated by Layla; (iii) your violation of any of these terms; or (iii) your violation of the rights of any third party.
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    Your therapist is a an independent practitioner contracted to Layla. You acknowledge that Layla Care Inc. itself is not providing treatment or other medical services to you. Layla makes suggested therapist matches to you based on the information provided by you and by them, and does not guarantee their ability to assist you. Therapists contacted to Layla are solely responsible – as independent providers - for the provision of professional health services as they deem appropriate. Any dispute between you and a therapist is strictly between you and such therapist Layla. You agree to indemnify and hold Layla, its directors, officers, employees, agents and shareholders, harmless from any claims, demands, losses, liabilities, and expenses arising in connection with: (i) your use of the Layla’s services, (ii) Healthcare services provided by an independent provider facilitated by Layla; (iii) your violation of any of these terms; or (iii) your violation of the rights of any third party.
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    Auto calculated based on Referral Channel
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