Start Now! Enroll Online

Please complete the below enrollment form and tell us what you are looking for in terms of individual and/or group counselling, and if possible, which program you wish to take. If you are unsure, you can request a general assessment. Note that all services have a cost – please refer to the Fees and Payment page.

All the information you send us will be private and confidential.

Individual and Group Anger Management services require a pre-payment for the assessment interview.

Once you submit an enrollment form, one of our staff will contact you within 4 business days to arrange an appointment. Please wait for us to contact you.

If you are in crisis, please contact:
Mental Health Crisis Line: 1-866-966-0991
Distress Centre: 613-238-3311
911 or go to the closest Emergency Room

Contact Information

Your Name:

Partner's Name (if requesting couples counselling):

Your Date of Birth (mm/yyyy):

Street Address:

City:

Province:

Postal Code:

Country:

Email:

Can we send you an email message?:

Home Phone:

Can we leave a message?:

Cell Phone:

Can we leave a message?:

Work Phone:

Can we leave a message?:

Emergency Contact:

Relation:

Contact Number:

Family Doctor:

Clinic Name:

Contact Number:

Additional Information

How did you hear about us?:

Do you have Extended Healthcare Benefits?

If you answered "Yes" to having Extended Healthcare Benefits, please provide the name of your provider:

Type of Service Being Requested:

Brief Description of Concerns:

Method of Payment:

"Pay by third party” means that payment will be made directly by an outside organization or individual rather than the client. Please provide the Third Party’s name and contact information. Note we cannot proceed with services until written confirmation is received via: info@menandhealing.ca, or by fax) from the third party.