Individual & Couples Intake Salesforce

1
I'm here for* This field is required.
Individual therapy
Couples counselling
Therapy for child/teen (16 or under)
2
Parent or guardian consent* This field is required.For clients 16 years or younger, Layla requires consent of parent or guardian
3
What is the main area you are looking for support with?* This field is required.
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
4
What is the main area you are looking for support with as a couple?* This field is required.
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
5
What other areas are you also looking for support with?Select all that apply
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
6
What other areas are you also looking for support with as a couple?
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
7
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
8
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
9
Have you received a psychological diagnosis from a qualified healthcare professional?Skip if not applicable
Adjustment disorder
Agoraphobia
Anorexia Nervosa
Antisocial personality disorder
Anxiety (Unspecified)
Any diagnosis related to neglect/abuse
Any Psychotic disorder
Any Sexual Disorder
Any Sleep Disorder (Incl. Insomnia)
Any Substance Use Disorder
Attention-deficit/hyperactivity 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
10
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
11
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
12
Rate your physical health* This field is required.
Good
Fair
Poor
13
Rate your sleep habits* This field is required.
Good
Fair
Poor
14
Rate your eating habits* This field is required.
Good
Fair
Poor
15
How often do you drink alcohol?* This field is required.
Daily
Weekly/Monthly
Infrequently/Never
16
How often do you engage in recreational drug use?* This field is required.
Daily
Weekly/Monthly
Infrequently/Never
17
How are you doing in school?* This field is required.
Good
Fair
Poor
Not in school
18
What is your relationship status?* This field is required.Select all that apply
Single
Dating
Living together
Common law
Married
Divorced
Separated
Living apart
Widowed
Not sure
19
How would you rate your current relationship satisfaction?* This field is required.0 being poor and 10 being exceptional
20
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
21
When did you previously receive mental health services?* This field is required.Select all that apply
Recently (last 6 months)
Within last two years
2-5 years ago
Longer time ago
22
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
23
Is there any coercion present in the relationship toward either partner?If so, in what way?
24
Are there times when either of you feel afraid of the other partner?If so, in what way?
25
How long have you been in your current relationship?* This field is required.
Under 2 years
2-5 years
5+ years
26
Rate your commitment to working towards your current relationship goal(s) * This field is required.0 being poor and 10 being exceptional
27
What is your greatest strength as a couple?
28
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
29
Who do you live with?* This field is required.
30
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
31
Are you interested in a specific psychotherapy treatment?Skip if not, or not sure
CBT-Structured
DBT-Structured
EMDR
EFT
Mindfulness
Psychodynamic
Anti-Oppressive Practice
Short-Term Solution-Focused
Narrative Therapy
Somatic
Hypnotherapy
32
Do you have additional preferences for your therapist?For example: from a certain minority community, identifies as a certain gender, understands a culture, speaks a certain language
33
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
34
What's your preferred setting for sessions?* This field is required.Layla's individual and couples counselling is only available to Ontario residents at this time
Phone
Video chat
In-person (when things open up)
Combination
35
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
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
36
Enter postal code to be used for matching with a therapistThis can be the same as your home, your work, or other preferred postal code
Street Address
Street Address Line 2
City
State / Province
Postal Code
Please Select
Please Select
United States
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
Curacao
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
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
37
How flexible are you with location for the right therapist?* This field is required.
Flexible
Somewhat flexible
Not flexible at all
38
Do you require an office that is wheelchair accessible?
Yes
No
39
When is generally convenient for you? Select all that apply* This field is required.
Weekday morning
Weekday noon / afternoon
Weekday evenings
Weekends
40
How flexible are you with when you can see your therapist?
Flexible
Somewhat flexible
Not flexible at all
41
Planning to use benefits? Who are you covered for?* This field is required.All our therapists are licenced to conduct Psychotherapy in their jurisdiction
Registered Social Worker (RSW)
Registered Psychotherapist (RP)
Not sure for now
Not using benefits
42
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
43
What are your pronouns?
She/her/hers
He/him/his
They/them/theirs
44
Email* This field is required.
example@example.com
Confirm Email
45
Phone Number* This field is required.
Area Code
Phone Number
46
May we leave a voicemail?* This field is required.
Yes
No
47
Partner's name* This field is required.
First Name
Last Name
48
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
49
Partner's pronouns
She/her/hers
He/him/his
They/them/theirs
50
Address* This field is required.Layla's individual and couples counselling is only available to Ontario residents at this time
Street Address
Street Address Line 2
City
Province
Postal Code
Please Select
Please Select
United States
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
Curacao
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
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
51
Address - Text
Huge
Large
Normal
Small
Ok
Ok
52
Date of Birth* This field is required.
Date
Year
Month
Day
53
Partner's date of birth* This field is required.
Date
Year
Month
Day
54
Parent/Guardian Information* This field is required.Include name(s), relationship to you, contact info (phone, email)
55
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
56
Emergency contact* This field is required.Please provide name, phone, email, and relationship to you
0/40
57
How did you hear about us?
Family or friend
Online search
Family Doctor
Other health/wellness professional
Other
58
For continuity of care, can we let your Family Doctor and referring provider (if applicable) know the name of your therapist and appointment date if a match is made?* This field is required.
Yes
No
59
Family Doctor* This field is required.Name and area/region
60
Referring Provider* This field is required.Name and area/region
61
Referring provider designation* This field is required.
General Practitioner
Psychiatrist
Psychologist
Social Worker/Psychotherapist
Naturpath
Dietitian/Nutritionist
Other healthcare provider
Other community worker
62
A couple of things to know* This field is required.Layla's individual and couples counselling is only available to Ontario 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.
63
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
64
Fees and Cancellation Policy* This field is required.A standard session length is 50 minutes and cost $130 ($170 for couples) including applicable taxes if any. 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.
65
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
66
Therapist is an independent practitioner* This field is required.
67
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.
68
Please verify that you are human* This field is required.
69
Should be Empty: