Individual & Couples Intake Salesforce

1
I'm here for* This field is required.
Individual therapy
Couples counselling
Therapy for child/teen (16 or under)
Lower cost therapy (supervised therapists, limitations and eligibility criteria apply)
Diagnostic psychological assessment
2
You don’t need a diagnostic psychological assessment to start therapy with Layla. This evaluation, costing $1350, diagnoses conditions like ADHD, Depression, Anxiety, or PTSD and includes a report.* This field is required.If you want therapy, please go BACK
I would like to proceed with a diagnostic assessment (with an option to book a call or email questions before booking; redirect me)
I’m unsure about proceeding and would like to speak with a coordinator first.
3
Supervised Therapy (lower cost) sessions are with a clinically supervised trainee. Limitations apply to ensure we can properly support. Available for adults in Ontario presenting with mild to moderate health concerns.Go BACK below if this is not what you're looking for.
I understand. Redirect me to the Supervised Therapy eligibility form
4
SF - I'm here for
Individual therapy
Couples counselling
Therapy for child/teen (16 or under)
5
Layla is not a crisis service (For other crisis resources click here)* This field is required.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.
I am not dealing with an immediate safety concern.
6
Parent or guardian consent* This field is required.For clients 16 years or younger, Layla requires consent of parent or guardian
7
Parent or guardian consent (For other resources check here)* This field is required.For clients 16 years or younger, Layla requires consent of parent or guardian
This form is being filled with or by a parent or guardian
8
What is the main area you are looking for support with at this time?* This field is required.
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
9
What is the main area you are looking for support with at this time?* This field is required.
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
10
What is the main area you are looking for support with as a couple?* This field is required.
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
11
What is the main area you are looking for support with as a couple?* This field is required.
Amicable separation
Co-parenting (parents who are not currently in a romantic relationship together)
Conflict related to financial issues
Conflict Resolution
Court-mandated
Cultural differences or Cross-Cultural Relationship
Division of responsibilities
Enhancing or Increasing Quality Time
Extended family dynamics/Family of Origin
Fertility Challenges or Post-Partum
Grief & Loss
Improve Communication
Infidelity
Intimacy (emotional)
Intimacy (sexual)
Major life changes (e.g., new job, long distance, empty nest, etc.)
Navigating alternative and/or non-monogamous relationships
Navigating Chronic Illness/Pain as a Couple
Navigating neurodivergence as a couple
Navigating trauma as a couple
New Parents or Parenting Skills
Power and control issues
Sexual dysfunction
Sexual or Gender Identity
Substance Abuse Recovery/Support
12
Select up to three other areas you may also be looking for support with at this timePlease 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
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
13
What other areas are you also looking for support with?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
14
What other areas are you also looking for support with as a couple?
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
15
What other areas are you also looking for support with as a couple?Optional, select up to 3
Amicable separation
Co-parenting (parents who are not currently in a romantic relationship together)
Conflict related to financial issues
Conflict Resolution
Court-mandated
Cultural differences or Cross-Cultural Relationship
Division of responsibilities
Enhancing or Increasing Quality Time
Extended family dynamics/Family of Origin
Fertility Challenges or Post-Partum
Grief & Loss
Improve Communication
Infidelity
Intimacy (emotional)
Intimacy (sexual)
Major life changes (e.g., new job, long distance, empty nest, etc.)
Navigating alternative and/or non-monogamous relationships
Navigating Chronic Illness/Pain as a Couple
Navigating neurodivergence as a couple
Navigating trauma as a couple
New Parents or Parenting Skills
Power and control issues
Sexual dysfunction
Sexual or Gender Identity
Substance Abuse Recovery/Support
16
How long have you been dealing with these challenges?* This field is required.
Recently (one month or less)
Within 2-6 months
6-12 months
12+ months
17
SF - How long have you been dealing with these challenges?
Recently (one month or less)
Within 2-6 months
6-12 months
12+ months
18
How much are these issues impacting your day-to-day (mood, relationships, work, health)?* This field is required.
Starting to impact/impacting now and then
Moderate/frequent impact
Significant/regular impact
Serious and constant impact
19
SF - How much are these issues impacting your day-to-day (mood, relationships, work, health)?
Starting to impact/impacting now and then
Moderate/frequent impact
Significant/regular impact
Serious and constant impact
20
Have you received a psychological diagnosis from a qualified healthcare professional?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
21
Are you in touch with a physician about your mental health / medications?* This field is required.
No
Irregularly
A few times per year
Monthly or more
22
SF - Are you in touch with a physician about your mental health / medications?
No
Irregularly
A few times per year
Monthly or more
23
Are you currently taking any psychiatric medications?
No
Recently started & helpful
Recently started & not clear if helpful
> 3 months & helpful
> 3 months & not that helpful
24
SF - Are you currently taking any psychiatric medications?
No
Recently started & helpful
Recently started & not clear if helpful
> 3 months & helpful
> 3 months & not that helpful
25
Rate your physical health* This field is required.
Good
Fair
Poor
26
SF - Rate your physical health
Good
Fair
Poor
27
Rate your sleep habits* This field is required.
Good
Fair
Poor
28
SF - Rate your sleep habits
Good
Fair
Poor
29
Rate your eating habits* This field is required.
Good
Fair
Poor
30
SF - Rate your eating habits
Good
Fair
Poor
31
How often do you drink alcohol?* This field is required.
Daily
Weekly/Monthly
Infrequently/Never
32
SF - How often do you drink alcohol?
Daily
Weekly/Monthly
Infrequently/Never
33
How often do you engage in recreational drug use?* This field is required.
Daily
Weekly/Monthly
Infrequently/Never
34
SF - How often do you engage in recreational drug use?
Daily
Weekly/Monthly
Infrequently/Never
35
How are you doing in school?* This field is required.
Good
Fair
Poor
Not in school
36
SF - How are you doing in school?
Good
Fair
Poor
Not in school
37
What is your relationship status?* This field is required.Select all that apply
Click to select
Single
Dating
Living together
Common law
Married
Divorced
Separated
Living apart
Widowed
Not sure
38
How would you rate your current relationship satisfaction?0 being poor and 10 being exceptional
39
How would you rate your current relationship satisfaction?* This field is required.1 being poor and 10 being exceptional
Please select a number between 1 and 10
Please select a number between 1 and 10
1
2
3
4
5
6
7
8
9
10
40
How would you rate your current relationship satisfaction?* This field is required.1 being poor and 10 being exceptional
1
2
3
4
5
6
7
8
9
10
41
SF - How would you rate your current relationship satisfaction?
42
Have you previously received any type of mental health services?* This field is required.Select all that apply
No
Psychiatric services
Individual therapy
Couples/family therapy
Group therapy
43
When did you previously receive mental health services?* This field is required.
Recently (last 6 months)
Within last two years
2-5 years ago
Longer time ago
44
Do either of you have a problem with alcohol or drug use?Briefly elaborate on the nature of the problem (e.g. substance, reason for concern, etc.). Skip if not applicable
45
Is there any coercion present in the relationship toward either partner?If so, in what way?
46
Are there times when either of you feel afraid of the other partner?* This field is required.
Yes
No
47
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.
48
Please share in general terms the types of situation(s) where you've been afraid of your partner
49
Who is filling out this form?* This field is required.We will directly follow up with the individual who has indicated yes to feeling afraid of the other partner
50
How long have you been in your current relationship?* This field is required.
Under 2 years
2-5 years
5+ years
51
SF - How long have you been in your current relationship?
Under 2 years
2-5 years
5+ years
52
Rate your commitment to working towards your current relationship goal(s)0 being poor and 10 being exceptional
53
Rate your commitment to working towards your current relationship goal(s)* This field is required.1 being poor and 10 being exceptional
Please select a number between 1 and 10
Please select a number between 1 and 10
1
2
3
4
5
6
7
8
9
10
54
SF - Rate your commitment to working towards your current relationship goal(s)
55
What is your greatest strength as a couple?
56
How frequently could you commit to couples therapy?* This field is required.Generally, couples counselling begins weekly or bi-weekly and may taper down, but it depends on the therapist and clients’ specific case
1 Session per week
1-2 Sessions per month
Less than 1 session per month
Don't know
57
SF - How frequently could you commit to couples therapy?
1 Session per week
1-2 Sessions per month
Less than 1 session per month
Don't know
58
Who do you live with?* This field is required.
59
Layla is not a crisis service* This field is required.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
60
What are your preferred settings for sessions?* This field is required.
Phone
Video
In-person
Walk and Talk Therapy
61
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.
62
Where is a convenient location(s) for you?* This field is required.Our in-person therapists are location across GTA and surrounding areas. Go back to choose remote only options
Click to select
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
63
How flexible are you with location for the right therapist?* This field is required.
Flexible
Somewhat flexible
Not flexible at all
64
Do you require an office that is wheelchair accessible?
Yes
No
65
SF - Do you require an office that is wheelchair accessible?
Yes
No
66
DEACTIVATED SEPT 24 2024 - When is generally convenient for you? Select all that apply* This field is required.
Weekday morning
Weekday noon / afternoon
Weekday evenings
Weekends
67
What is the best availability for your therapy appointments?* This field is required.
I have a flexible schedule and can make most times work for therapy
I require weekends
I require weekday evenings (after 5:00)
I could do evenings after 5pm or weekends
I require weekday daytime (between 9:00 & 5:00)
I have limited flexibility (e.g., specific day of the week) and need to provide specific times
68
Which days do you want specify your availability? (select all that apply)* This field is required.
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
69
On Mondays, what times are you generally available for therapy appointments?* This field is required.Please ensure the Start Time is earlier than the End Time
Please Select
Please Select
7 am
8 am
9 am
10 am
11 am
12 pm
1 pm
2 pm
3 pm
4 pm
5 pm
6 pm
7 pm
8 pm
9 pm
10 pm
Monday Start Time
Please Select
Please Select
7 am
8 am
9 am
10 am
11 am
12 pm
1 pm
2 pm
3 pm
4 pm
5 pm
6 pm
7 pm
8 pm
9 pm
10 pm
Monday End Time
70
Calc - Monday Start Time
71
SF - Monday Start Time
7 am
8 am
9 am
10 am
11 am
12 pm
1 pm
2 pm
3 pm
4 pm
5 pm
6 pm
7 pm
8 pm
9 pm
10 pm
72
Calc - Monday End Time
73
SF - Monday End Time
7 am
8 am
9 am
10 am
11 am
12 pm
1 pm
2 pm
3 pm
4 pm
5 pm
6 pm
7 pm
8 pm
9 pm
10 pm
74
On Tuesdays, what times are you generally available for therapy appointments?* This field is required.Please ensure the Start Time is earlier than the End Time
Please Select
Please Select
7 am
8 am
9 am
10 am
11 am
12 pm
1 pm
2 pm
3 pm
4 pm
5 pm
6 pm
7 pm
8 pm
9 pm
10 pm
Tuesday Start Time
Please Select
Please Select
7 am
8 am
9 am
10 am
11 am
12 pm
1 pm
2 pm
3 pm
4 pm
5 pm
6 pm
7 pm
8 pm
9 pm
10 pm
Tuesday End Time
75
Calc - Tuesday Start Time
76
SF - Tuesday Start Time
7 am
8 am
9 am
10 am
11 am
12 pm
1 pm
2 pm
3 pm
4 pm
5 pm
6 pm
7 pm
8 pm
9 pm
10 pm
77
Calc - Tuesday End Time
78
SF - Tuesday End Time
7 am
8 am
9 am
10 am
11 am
12 pm
1 pm
2 pm
3 pm
4 pm
5 pm
6 pm
7 pm
8 pm
9 pm
10 pm
79
On Wednesdays, what times are you generally available for therapy appointments?* This field is required.Please ensure the Start Time is earlier than the End Time
Please Select
Please Select
7 am
8 am
9 am
10 am
11 am
12 pm
1 pm
2 pm
3 pm
4 pm
5 pm
6 pm
7 pm
8 pm
9 pm
10 pm
Wednesday Start Time
Please Select
Please Select
7 am
8 am
9 am
10 am
11 am
12 pm
1 pm
2 pm
3 pm
4 pm
5 pm
6 pm
7 pm
8 pm
9 pm
10 pm
Wednesday End Time
80
Calc - Wednesday Start Time
81
SF - Wednesday Start Time
7 am
8 am
9 am
10 am
11 am
12 pm
1 pm
2 pm
3 pm
4 pm
5 pm
6 pm
7 pm
8 pm
9 pm
10 pm
82
Calc - Wednesday End Time
83
SF - Wednesday End Time
7 am
8 am
9 am
10 am
11 am
12 pm
1 pm
2 pm
3 pm
4 pm
5 pm
6 pm
7 pm
8 pm
9 pm
10 pm
84
On Thursdays, what times are you generally available for therapy appointments?* This field is required.Please ensure the Start Time is earlier than the End Time
Please Select
Please Select
7 am
8 am
9 am
10 am
11 am
12 pm
1 pm
2 pm
3 pm
4 pm
5 pm
6 pm
7 pm
8 pm
9 pm
10 pm
Thursday Start Time
Please Select
Please Select
7 am
8 am
9 am
10 am
11 am
12 pm
1 pm
2 pm
3 pm
4 pm
5 pm
6 pm
7 pm
8 pm
9 pm
10 pm
Thursday End Time
85
Calc - Thursday Start Time
86
SF - Thursday Start Time
7 am
8 am
9 am
10 am
11 am
12 pm
1 pm
2 pm
3 pm
4 pm
5 pm
6 pm
7 pm
8 pm
9 pm
10 pm
87
Calc - Thursday End Time
88
SF - Thursday End Time
7 am
8 am
9 am
10 am
11 am
12 pm
1 pm
2 pm
3 pm
4 pm
5 pm
6 pm
7 pm
8 pm
9 pm
10 pm
89
On Fridays, what times are you generally available for therapy appointments?* This field is required.Please ensure the Start Time is earlier than the End Time
Please Select
Please Select
7 am
8 am
9 am
10 am
11 am
12 pm
1 pm
2 pm
3 pm
4 pm
5 pm
6 pm
7 pm
8 pm
9 pm
10 pm
Friday Start Time
Please Select
Please Select
7 am
8 am
9 am
10 am
11 am
12 pm
1 pm
2 pm
3 pm
4 pm
5 pm
6 pm
7 pm
8 pm
9 pm
10 pm
Friday End Time
90
Calc - Friday Start Time
91
SF - Friday Start Time
7 am
8 am
9 am
10 am
11 am
12 pm
1 pm
2 pm
3 pm
4 pm
5 pm
6 pm
7 pm
8 pm
9 pm
10 pm
92
Calc - Friday End Time
93
SF - Friday End Time
7 am
8 am
9 am
10 am
11 am
12 pm
1 pm
2 pm
3 pm
4 pm
5 pm
6 pm
7 pm
8 pm
9 pm
10 pm
94
On Saturdays, what times are you generally available for therapy appointments?* This field is required.Please ensure the Start Time is earlier than the End Time
Please Select
Please Select
7 am
8 am
9 am
10 am
11 am
12 pm
1 pm
2 pm
3 pm
4 pm
5 pm
6 pm
7 pm
8 pm
9 pm
10 pm
Saturday Start Time
Please Select
Please Select
7 am
8 am
9 am
10 am
11 am
12 pm
1 pm
2 pm
3 pm
4 pm
5 pm
6 pm
7 pm
8 pm
9 pm
10 pm
Saturday End Time
95
Calc - Saturday Start Time
96
SF - Saturday Start Time
7 am
8 am
9 am
10 am
11 am
12 pm
1 pm
2 pm
3 pm
4 pm
5 pm
6 pm
7 pm
8 pm
9 pm
10 pm
97
Calc - Saturday End Time
98
SF - Saturday End Time
7 am
8 am
9 am
10 am
11 am
12 pm
1 pm
2 pm
3 pm
4 pm
5 pm
6 pm
7 pm
8 pm
9 pm
10 pm
99
On Sundays, what times are you generally available for therapy appointments?* This field is required.Please ensure the Start Time is earlier than the End Time
Please Select
Please Select
7 am
8 am
9 am
10 am
11 am
12 pm
1 pm
2 pm
3 pm
4 pm
5 pm
6 pm
7 pm
8 pm
9 pm
10 pm
Sunday Start Time
Please Select
Please Select
7 am
8 am
9 am
10 am
11 am
12 pm
1 pm
2 pm
3 pm
4 pm
5 pm
6 pm
7 pm
8 pm
9 pm
10 pm
Sunday End Time
100
Calc - Sunday Start Time
101
SF - Sunday Start Time
7 am
8 am
9 am
10 am
11 am
12 pm
1 pm
2 pm
3 pm
4 pm
5 pm
6 pm
7 pm
8 pm
9 pm
10 pm
102
Calc - Sunday End Time
103
SF - Sunday End Time
7 am
8 am
9 am
10 am
11 am
12 pm
1 pm
2 pm
3 pm
4 pm
5 pm
6 pm
7 pm
8 pm
9 pm
10 pm
104
DEACTIVATED SEPT 24 2024 - How flexible are you with when you can see your therapist?
Flexible
Somewhat flexible
Not flexible at all
105
SF - How flexible are you with when you can see your therapist?
Flexible
Somewhat flexible
Not flexible at all
106
Are you looking for support to be covered by a disability insurance claim?* This field is required.
WSIB
Private Disability Insurance
Not Applicable
107
Planning to use benefits? Who are you covered for?* This field is required.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.
Registered Social Worker (RSW)
Registered Psychotherapist (RP)
Registered Counselling Therapist (RCT)
Psychologist
Not sure for now
Not using benefits
108
Are you currently off work temporarily on disability leave due to injury or illness or engaged in a gradual return-to-work?
Yes
No
109
How are you planning to pay for your sessions?
Using extended health benefits provided through my employer
Funding from a disability claim (through a private insurer like Manulife, Sunlife, Canada Life, etc.)
Funding from a short or long term disability claim (For ON clients only - through WSIB)
I don’t know - I could use help figuring out if I have funding through a short or long term disability claim
Out of pocket
Other
110
What feels right for your therapy sessions (pick all that apply)?
Therapist leads more
Therapist lets me lead
More structured
More exploratory
Skill-building and homework
Passive and introspective
Balanced approach
Don't know
111
Are you looking for a therapist of a specific gender?* This field is required.
YESNo Preference
112
Please select at least one of the following gender identity options from the list below* This field is required.
Man
Woman
Trans man
Trans woman
Non binary
Agender
Two spirit
Gender neutral
Pangender
Genderqueer
Third gender
Gender Fluid
Other
113
Do you have additional preferences for your therapist (e.g., language, ethnocultural or religious background, specialization with a certain population, specific treatment modality).* This field is required.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.
YESNo Preference
114
While we make every effort to accommodate requests to match on personal factors such as language, race, religion, and lived experience, we cannot always guarantee that we have available therapists who align well on all logistical, clinical, and interpersonal requests of a client. Our Care Coordination Team will work diligently with you to identify the best possible match from our available therapists, ensuring that your care and your priorities for a therapist remain our top priority.* This field is required.
I understand
115
Are you interested in a specific psychotherapy treatment?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
116
Are you looking for a therapist who specializes in or has lived experience with LGBTQ2S+ issues?* This field is required.
YesNo Preference
117
SF - Are you looking for a therapist who specializes in or has lived experience with LGBTQ2S+ issues?
Yes
No Preference
118
DEACTIVATED SEPT 23 2024 - Are you looking for a therapist who identifies as Black, Indigenous, a Person of Colour?* This field is required.
YESNo Preference
119
Please select at least one of the options from the list below* This field is required.
African, Caribbean, Black
Indigenous
Person of Color
Arab
Middle Eastern or North African
Central Asian
South Asian
East Asian
Southeast Asian
Latin/Latinx
Eastern European
120
Is it important for you to work with a therapist of a specific race?* This field is required.
YESNo Preference
121
Please select at least one of the racial identities from the listWe 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
Arab
Black
Latin/Latinx
Indigenous
East Asian
South Asian
Southeast Asian
Mixed Ethnic &/or Racial Background
122
Is it important to you to work with a therapist who has lived experience in a specific country or region?* This field is required.
YESNo Preference
123
The following 2 questions are related to your request to be matched based on lived experience in a country or region. These questions are optional.* This field is required.
I understand
124
Please choose from the country list by typing the country name (optional)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
125
Please choose from one of the following regions (optional)
Arab States
Caribbean
Central Asia
Central America
East Asia and the Pacific
Eastern Europe
Latin America
Oceania
South Asia
Sub-Saharan Africa
Western Europe
126
Are you looking for a therapist who offers sessions in a language other than English?
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
Inuit Languages
Italian
Japanese
Javanese
Jin
Kannada
Kazakh
Khmer
Kinyarwanda
Kirundi
Konkani
Korean
Kurdish
Madurese
Magahi
Maithili
Malagasy
Malay (inc. Indonesian and Malaysian)
Malayalam
Mandarin
Mandarin (entire branch)
Marathi
Marwari
Mossi
Nepali
Northern Min[disputed – discuss]
Odia (Oriya)
Ojibway
Oji-Cree
Oromo
Other
Pashto
Persian/Farsi
Polish
Portuguese
Punjabi
Quechua
Romanian
Russian
Saraiki
Serbian
Serbo-Croatian
Shona
Sindhi
Sinhala
Somali
Southern Min
Southern Min (inc. Hokkien and Teochew)
Spanish
Sundanese
Swahili
Swedish
Sylheti
Tagalog (Filipino)
Tamil
Telugu
Thai
Turkish
Turkmen
Ukrainian
Urdu
Uyghur
Uzbek
Vietnamese
Western Punjabi (Lahnda)
Wu (inc. Shanghainese)
Wu Chinese (incl. Shanghainese)
Xhosa
Xiang
Yoruba
Yue (inc. Cantonese)
Zhuang
127
Are you looking for a therapist with an understanding of a specific religion?* This field is required.
YESNo Preference
128
Please select at least one of the religion options from the list below* This field is required.
Bahai
Buddhism
Druze
Christianity
Hinduism
Judaism
Islam
Shinto
Sikhism
Traditional (Indigenous) Spirituality
Non-Religious
Other
129
Do you have additional preferences for your therapist?For example: works with a concern or diagnosis not previously listed
130
Your name* This field is required.Please write your full name below. If you're a parent/guardian seeking support for a child, enter child's name.
First Name
Last Name
131
Your name is important to us! How would you like us to pronounce it? Feel free to provide a phonetic spelling, or any other helpful tips. (Optional)For example, if your name is Amira, you could write it as "Ah-meer-ah
132
What are your pronouns?* This field is required.
She/her/hers
He/him/his
They/them/theirs
Other
133
What are your pronouns?* This field is required.
She/her/hers
He/him/his
They/them/theirs
Other
134
Your email* This field is required.
example@example.com
Confirm Email
135
Your phone number* This field is required.
(###) ###-####
136
May we leave a voicemail?* This field is required.
Yes
No
137
SF - May we leave a voicemail?
Yes
No
138
Partner's name* This field is required.
First Name
Last Name
139
Your partner's name is important to us as well! How would you like us to pronounce it? Feel free to provide a phonetic spelling, or any other helpful tips. (Optional)For example, if your name is Amira, you could write it as "Ah-meer-ah
140
Partner's phone number* This field is required.By providing us with your partner's phone number they consent to receiving communications from the Layla Care team.
(###) ###-####
141
Partner's email* This field is required.By providing us with your partner's email they consent to receiving communications from the Layla Care team.
example@example.com
142
Partner's pronouns
She/her/hers
He/him/his
They/them/theirs
Other
143
Partner's pronouns* This field is required.
She/her/hers
He/him/his
They/them/theirs
Other
144
Your home address* This field is required.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.
Street Address
Street Address Line 2
City
ON
ON
ON
AB
BC
NS
Province
Postal Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
145
Therapist Distance
146
Address - Text
Huge
Large
Normal
Small
Ok
Ok
147
Your date of birth* This field is required.
Tip: Enter date directly in the format YYYY-MM-DD to bypass calendar navigation!
Year
Month
Day
148
Partner's date of birth* This field is required.
Tip: Enter date directly in the format YYYY-MM-DD to bypass calendar navigation!
Year
Month
Day
149
Parent/Guardian Information* This field is required.Include name(s), relationship to you, contact info (phone, email)
150
Who will pay for your sessions?* This field is required.Provide name and email of person paying for sessions. By providing their name and email below, they consent to being contacted by Layla
151
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.
152
Emergency contact* This field is required.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.
0/255
153
How did you hear about us?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).
Family or friend
Online search
Family Doctor
Psychiatrist
Health/wellness professional
Employer
OVMA/Veterinary Community
Other
154
What is the name of your employer? (optional)We will not reveal any information with your employer.
155
SF - How did you hear about us?
Family or friend
Online search
Family Doctor
Psychiatrist
Health/wellness professional
Employer
OVMA/Veterinary Community
Other
156
Referring {howDid} Name and Location
Name
Location (you can leave it blank if location is not available)
157
SF - {howDid} Name
158
SF - {howDid} Location
159
Health/Wellness Professional Name* This field is required.
First Name
Last Name
160
Health/Wellness Professional Designation* This field is required.
Nurse Practitioner
Psychologist
Pharmacist
Social Worker/Psychotherapist
Naturopath
Dietitian/Nutritionist
Other community worker
Other healthcare provider
161
For continuity of care, can we update your {howDid}?* This field is required.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.
Yes
No
162
For continuity of care, can we update your Family Doctor?* This field is required.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.
Yes
No
163
SF - For continuity of care, can we update your Family Doctor?
Yes
No
164
Family Doctor Name* This field is required.
First Name
Last Name
165
Family Doctor CitySkip if not applicable
166
Family Doctor Phone Number* This field is required.
(###) ###-####
167
Family DoctorName and area/region
168
Referring ProviderName and area/region
169
A couple of things to know* This field is required.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.
170
A couple of things to knowLayla'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.
I understand
171
Privacy of your information* This field is required.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
172
Privacy of your information (Click here to see Layla’s Privacy Policy)* This field is required.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
I agree to Layla's Privacy Policy
173
Fees and Cancellation Policy* This field is required.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.
174
Fees and Cancellation Policy* This field is required.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.
I understand and agree
175
First Session Reservation Policy* This field is required.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.
I understand and agree
176
Fees and Cancellation Policy* This field is required.Layla's intake call is free. Fees for subsequent therapy sessions apply. Layla's services are not covered by OHIP
177
Therapist is an independent practitioner* This field is required.
178
Therapist is an independent practitioner* This field is required.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.
179
Therapist is an independent practitioner* This field is required.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.
I understand and agree
180
Intake Form Complete - For Salesforce Integration
Intake Form Complete
181
Intake Version - For Salesforce Integration
182
SF - Health/Wellness Professional Designation
Nurse Practitioner
Psychiatrist
Psychologist
Pharmacist
Social Worker/Psychotherapist
Naturopath
Dietitian/Nutritionist
Other community worker
Other healthcare provider
183
ScheduleOnce integration - calc field
184
Global Modality
Individual
Couples
185
SF - TPOPAuto calculated based on Referral Channel
OVMA Trained
Should be Empty: