Intake Form | Mental Health Copilots | Mental Health Copilots

Book an Appointment with a Mental Health Copilot

To set an appointment online, simply fill out the following form:

Filling out this form helps your Mental Health Copilot be prepared for your appointment.
We will contact you via email to set up the specifics of your appointment.
If this form feels like a little too much right now, feel free to just send us an email or Facebook message!

First Name Email Age Bracket Primary Concern This selection gives your Copilot an idea of which professionals to look into! Secondary Concern Do you have psychology insurance coverage? Yes
No
Not Sure If yes, who is your insurance provider? Your Copilot can look for psychologists who can bill directly to your insurance. What is your postal code? Your Copilot will use your postal code to find service options close to you! If you have previously tried therapy, what seemed to work for you? Or what didn't? Would your ideal therapist specialize in any particular language, orientation or people group? If so, which? How did you hear about Mental Health Copilots? By submitting this form, I understand that Mental Health Copilots (MHC) is a referral service only. MHC will not provide counselling or professional services, nor will it provide emergency mental health support. MHC does not guarantee success in finding a mental health professional, but our volunteers are here to help you every step of the way! I have read and understand the above disclosures.