Supervised Therapy Intake Form

1
uuid
2
What is the main area you are looking for support with at this time?* This field is required.Please note if you do not see your concern listed here it is because we are unable to support with it at this time. If your concern is not listed here, eMentalhealth.ca also provides a list of publicly-funded and subsidized services in Ontario
ADHD (strategies to manage)
Anxiety (incl. panic, GAD, and social)
Emotion regulation
Depression, sadness, or low mood
Family conflict
Life transitions/uncertainty
Relationship challenges
Self-esteem
Self-exploration
Sexual or gender identity
Stress/burnout
Work or school issues
3
Areas the Supervised Therapy Program do not support* This field is required.We are currently unable to see individuals who need support with the following areas: Anger management Behavioural 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 Dissociation Grief or loss OCD-related symptoms Parenting Personality disorder other than BPD Phobia(s) Pre- or Post-Natal challenges Psychosis Sexual abuse/assault (including childhood sexual abuse) Sexual dysfunction Skin-picking or hair-pulling Sleep concerns Substance use or addiction Trauma (single-incident) Trauma (multiple incident or ongoing) Our core service, Layla Therapy can connect clients with a therapist who can support a wider range of needs than our STP is equipped to. However, please note that Layla is not a crisis service.
I acknowledge that I do not need support with the areas listed above
4
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. If you don’t have anything further to add, feel free to skip this question Please note if you do not see your concern listed here it is because we are unable to support with it at this time.
ADHD (strategies to manage)
Anxiety (incl. panic, GAD, and social)
Emotion regulation
Depression, sadness, or low mood
Family conflict
Life transitions/uncertainty
Relationship challenges
Self-esteem
Self-exploration
Sexual or gender identity
Stress/burnout
Work or school issues
5
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
6
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
7
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.
8
Low risk acknowledgment* This field is required.For various reasons, Layla’s supervised therapy program is not able to support individuals who present with complex mental health needs. This includes clients who are experiencing active or ongoing thoughts about ending one’s life or who have had a recent suicide attempt (within the past 12 months). If needed, our core service, Layla Therapy can connect clients with a therapist who can support with a wider range of needs than our Supervised Therapy Program is equipped to. However, please note that Layla is not a crisis service.
I am not currently experiencing an immediate safety concern (e.g., suicidal thoughts with a plan to act on these thoughts) AND I have not had a suicide attempt or mental health-related hospitalization in the last 12 months
9
18+ age acknowledgement* This field is required.We are currently only able to see individuals 18 years and older. We hope to continue to expand our reach as we continue to grow this program!
I acknowledge that I am 18 years or older at this time
10
Areas the Supervised Therapy Program (STP) do not support (agreement on following page)

We are currently unable to see individuals who need support with the following areas:

Anger management

Behavioural 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

Dissociation

Grief or loss

OCD-related symptoms

Parenting

Personality disorder other than BPD

Phobia(s)

Pre- or Post-Natal challenges

Psychosis

Sexual abuse/assault (including childhood sexual abuse)

Sexual dysfunction

Skin-picking or hair-pulling

Sleep concerns

Substance use or addiction

Trauma (single-incident)

Trauma (multiple incident or ongoing)

Our core service, Layla Therapy can connect clients with a therapist who can support a wider range of needs than our STP is equipped to. However, please note that Layla is not a crisis service.
11
Psychological Diagnoses the Supervised Therapy program do not support (agreement on following page)

We are currently unable to see individuals who have received the following psychological diagnoses with the following areas:

Anorexia Nervosa

Antisocial personality disorder

Any Psychotic disorder

Binge-eating disorder

Bipolar Disorder (Type I or II)

Body dysmorphic disorder

Borderline Personality Disorder

Bulimia Nervosa

Conduct disorder

Delusional disorder

Dissociative identity disorder

Gender dysphoria

Hoarding disorder

Intermittent explosive disorder

Narcissistic personality disorder

OCD

Oppositional defiant disorder

Pyromania

Reactive attachment disorder

Skin-Picking or Hair-Pulling

Tourette’s disorder

Unspecified personality disorder

Our core service, Layla Therapy can connect clients with a therapist who can support a wider range of needs than our STP is equipped to. However, please note that Layla is not a crisis service.
12
Understanding Your Needs* This field is required.After you submit this form, we’ll review it to see how we can best help you. If we can meet your needs, we’ll send you a link via email to book a session with one of our therapists. If we cannot meet your needs, you will receive an email with alternative resources.
I understand and agree
13
SF - What is the main area you are looking for support with at this time? #hiddenPrimary Concern
ADHD (strategies to manage)
Anxiety (incl. panic, GAD, and social)
Emotion regulation
Depression, sadness, or low mood
Family conflict
Life transitions/uncertainty
Relationship challenges
Self-esteem
Self-exploration
Sexual or gender identity
Stress/burnout
Work or school issues
14
SF - How long have you been dealing with these challenges? #hiddenLength of Symptoms
Recently (one month or less)
Within 2-6 months
6-12 months
12+ months
15
SF - How much are these issues impacting your day-to-day (mood, relationships, work, health)? #hiddenImpact of Symptoms
Starting to impact/impacting now and then
Moderate/frequent impact
Significant/regular impact
Serious and constant impact
16
Have you received a psychological diagnosis from a qualified healthcare professional?You can skip this question by pressing Next if you haven't received a psychological diagnosis Please note if you do not see your diagnosis listed here it is because we are unable to support with it at this time. If we're unable to support given your diagnosis, eMentalhealth.ca also provides a list of publicly-funded and subsidized services in Ontario
ADHD (strategies to manage)
Adjustment disorder
Agoraphobia
Anxiety (Unspecified)
Any diagnosis related to neglect or abuse
Any Sexual Disorder
Any Sleep Disorder (Incl. Insomnia)
Any Substance Use Disorder
Autism spectrum disorder
Depression (Unspecified)
Enuresis
Gambling disorder
Generalized Anxiety
Health anxiety
Intellectual disability
Kleptomania
Major Depressive Disorder
Overweight or obesity
Panic Disorder/Panic attacks
PDD (dysthymia)
Premenstrual dysphoric disorder
PTSD
Separation anxiety disorder
Social Anxiety
Specific learning disorder
Specific phobia
17
Psychological Diagnoses the Supervised Therapy program do not support* This field is required.We are currently unable to see individuals who have received the following psychological diagnoses: Anorexia Nervosa Antisocial personality disorder Any Psychotic disorder Binge-eating disorder Bipolar Disorder (Type I or II) Body dysmorphic disorder Borderline Personality Disorder Bulimia Nervosa Conduct disorder Delusional disorder Dissociative identity disorder Gender dysphoria Hoarding disorder Intermittent explosive disorder Narcissistic personality disorder OCD Oppositional defiant disorder Pyromania Reactive attachment disorder Skin-Picking or Hair-Pulling Tourette’s disorder Unspecified personality disorder Our core service, Layla Therapy can connect clients with a therapist who can support a wider range of needs than our STP is equipped to. However, please note that Layla is not a crisis service.
I acknowledge that I have not received any of the psychological diagnoses listed above
18
Are you in touch with a physician about your mental health / medications? #hidden* This field is required.
No
Irregularly
A few times per year
Monthly or more
19
SF - Are you in touch with a physician about your mental health / medications? #hiddenHow Often in Touch with MD
No
Irregularly
A few times per year
Monthly or more
20
Are you currently taking any psychiatric medications?* This field is required.
No
Recently started & helpful
Recently started & not clear if helpful
> 3 months & helpful
> 3 months & not that helpful
21
SF - Are you currently taking any psychiatric medications? #hiddenPsychiatric Medications
No
Recently started & helpful
Recently started & not clear if helpful
> 3 months & helpful
> 3 months & not that helpful
22
Rate your physical health #hidden* This field is required.
Good
Fair
Poor
23
SF - Rate your physical health #hidden
Good
Fair
Poor
24
Rate your sleeping habits #hidden* This field is required.
Good
Fair
Poor
25
SF - Rate your sleeping habits #hiddenSleep Habits
Good
Fair
Poor
26
Rate your eating habits #hidden* This field is required.
Good
Fair
Poor
27
SF - Rate your eating habits #hiddenEating Habits
Good
Fair
Poor
28
Do you or does anyone close to you have any concerns about your alcohol use?* This field is required.
Yes
Unsure
No
29
SF - How often do you drink alcohol? #hiddenAlcohol
Daily
Weekly/Monthly
Infrequently/Never
30
Do you or does anyone close to you have any concerns about your recreational drug use?* This field is required.
Yes
Unsure
No
31
SF - How often do you engage in recreational drug use? #hiddenRecreational Drugs
Daily
Weekly/Monthly
Infrequently/Never
32
What is your relationship status? #hidden* This field is required.You can select all that apply
Single
Dating
Living together
Common law
Married
33
How would you rate your current relationship satisfaction? #hidden* This field is required.1 being poor and 10 being exceptional
1
2
3
4
5
6
7
8
9
10
34
SF - How would you rate your current relationship satisfaction? #hidden
1
2
3
4
5
6
7
8
9
10
35
Have you previously received any type of mental health services?* This field is required.You can select all that apply
No
Psychiatric services
Individual therapy
Couples/family therapy
Group therapy
36
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
37
SF - When did you previously receive mental health services? #hiddenDate of Previous Services
Recently (last 6 months)
Within last two years
2-5 years ago
Longer time ago
38
What is your name?* This field is required.Please write your full name below.
First Name
Last Name
39
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
40
What are your pronouns?* This field is required.
She/her/hers
He/him/his
They/them/theirs
Other
41
What is your email?* This field is required.
example@example.com
Confirm Email
42
What is your phone number?* This field is required.
43
May we leave a voicemail?* This field is required.
Yes
No
44
SF - May we leave a voicemail? #hidden
Yes
No
45
Ontario home province acknowledgement* This field is required.Our services are currently offered to individuals living in Ontario We hope to expand our reach to more provinces in the future!
I acknowledge I am currently located in Ontario
46
What is your home address?* This field is required.As acknowledged earlier, this program is only available to residents of Ontario. We will do our best to expand our services to more provinces in the future!
Street Address
Street Address Line 2
City
Please Select
Please Select
ON
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
47
What is your date of birth?* This field is required.As acknowledged earlier, this program is only available to individuals that are 18 years and older. We will do our best to expand our services to more age groups in the future!
Date
Year
Month
Day
48
Who will be your 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
49
How did you hear about us?* This field is required.
Family or friend
Online search
Family Doctor
Pharmacist
Health/wellness professional
Other
50
For continuity of care, can we update your Family Doctor?* This field is required.
Yes
No
51
SF - For continuity of care, can we update your Family Doctor? #hidden
Yes
No
52
What is the name of your family doctor?* This field is required.
First Name
Last Name
53
What city is your family doctor's clinic in?You can skip this question if you don't have this information available right now
54
Therapy availability and setting acknowledgement* This field is required.All therapy sessions will occur between Monday to Friday 9 am - 5 pm EST. All therapy sessions will be virtual and require a stable internet connection.
I acknowledge that all therapy sessions will be during regular business hours and will be virtual
55
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 24 hours before your first session. If payment information is not added by 24 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
56
Fees and Cancellation Policy* This field is required.A standard session length is 50 minutes and costs $55 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
57
Privacy of your information (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 understand and agree
58
Global Modality #hidden
STP
Should be Empty: