Memory Lane

Memory LaneMemory LaneMemory Lane
Home
Services
Resources
Contact Us
Client Forms

Memory Lane

Memory LaneMemory LaneMemory Lane
Home
Services
Resources
Contact Us
Client Forms
More
  • Home
  • Services
  • Resources
  • Contact Us
  • Client Forms

  • Home
  • Services
  • Resources
  • Contact Us
  • Client Forms

Client Forms

Please download and complete our client forms before your appointment if possible.

For Clients under 12 years of age, the parent or guardian must complete and sign all three forms labelled 1A for the client.

Clients 12 years of age and older will complete their own three forms labelled 1B.

If you are unable to print these, we can provide you with a physical copy and you may complete them at the beginning of your first session.

The time used to complete these forms will count towards the first 55-minute counselling session.

Client Consent Form 1A for minors and dependants (docx)Download
Client Intake Form 1A for minors and dependants (docx)Download
Client Service Agreement 1A for minors and dependants (docx)Download
Client Consent Form 1B Clients Ages 12-29 (docx)Download
Client Intake Form 1B Client Ages 12-29 (docx)Download
Client Service Agreement 1B Client Ages 12-29 (docx)Download
Informed Consent for Supervised Practice (Insurance providers with coverage for therapy with an RSW) (pdf)Download

Schedule Your Appointment

 Please click the link to choose a time that works for you.

Each 55 minute session has a fee of $110 +HST.

Your invoice will be emailed at the end of the session, payment is due upon receipt. 

Book Appointment

13133419 Canada Inc. - OACYC  Membership ID Number: 15780 

www.Memory-Lane.me - All Rights Reserved. Copyright © 2021

Powered by GoDaddy

This website uses cookies.

We use cookies to analyze website traffic and optimize your website experience. By accepting our use of cookies, your data will be aggregated with all other user data.

DeclineAccept