New Client Registration Form - Alivera Psychotherapy

Please enter your personal information on the form that follows.

If you would like to book your first session with one of Alivera’s therapists, please complete the registration form below. Please note that all fields are mandatory. If you have any concerns, please contact us for assistance.

Personal Information

First

Last

Email Address

Best number to reach you at

Is it okay to leave a voicemail?

Yes
No

Is it okay to text you?

Yes
No

Best date and time to book an appointment?

First

Last

Emergency Contact Information

First

Last

Address

Address Line 2

Province

Postal Code

Relationship

Family Doctor

First

Last

Clinic Name

Doctor Phone Number

Doctor Address

Doctor Province

Doctor Postal code

Do you consent for us to contact you to set up your first session and subsequent sessions with Alivera?

Yes
No

Who is the therapy for?

Reasons for Seeking Therapy

Other

If Other was selected, please provide a brief description for why you are seeking therapy.

Terms and Conditions

By selecting this box, you confirm that you have read, understand, and agree with the terms and conditions outlined on the FAQ page regarding payments, cancellation policy, consent, and confidentiality.
By selecting this box, you confirm that you are not presently experiencing a crisis or emergency situation. Please call 911 if this is an emergency or crisis.

For information about how payments work, cancellation policy, confidentiality, and consent please see our FAQ page for more information. If you have any questions or difficulties with completing this form, please contact us.

This form is for new clients. If you are already registered with Alivera and want to book a session, click here or at the top of the page.

New Client Registration

Please enter your personal information on the form that follows.

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