Consultations in Our Mental Health Centre in Chambly, Quebec

Please fill out this form before your first appointment. It will help us better understand your situation and match you with the professional who is best suited to your needs.

Part 1 : Your contact information

Part 2 : Desired service

Part 3 : Reasons for consultation

Part 4 : Vos attentes

Part 5 : Consent clauses

Name

Age

Email address

Phone

Preferred language for therapy

FrenchEnglishOther

Place of residence (province/country)

What type of therapy would you like?

Individual (for yourself)Couples (with your partner)Teen (for your child)

Do you have a preference regarding your therapist’s gender?

FemaleMaleNo preference

What plan do you prefer?

Pay per session

Individual session (60 minutes) : $140
Individual or teen session (90 minutes): $195
Couples’ session (60 minutes): $175
Couples’ session (90 minutes): $250

Wellness Package – 4 sessions

Individual 60-minute sessions: $520/month (save $80)
Couples’ 60-minute sessions = $680/month (save $80)
Individual or teen 90-minute sessions: $760/month (save $100)
Couples’ 90-minute sessions: $880/month (save $120)

*Every price listed is in Canadian Dollar (CAN)

Why do you seek counselling? Check all the reasons that apply.

Anxiety and stressDepressionAnger management and emotional regulationSelf-esteem, motivation or confidenceRelationship or family problemsCouples’ issuesTrauma or abuseGrief or lossIntimacy or sexualityEating disordersSleep disordersAddictionPhobiasBipolar disorderCognitive difficulties (ADHD, memory or concentration issues)Gender identity/orientation and LGBTQ+ mattersParentingProfessional difficulties or burnoutMajor life changesDomestic violenceOther

Have you ever seen a mental health professional?

YesNo

What are your main goals for therapy?

Understand my emotionsWork on a specific issueBe listened to in a safe spaceImprove my relationshipsLearn practical strategies to feel betterOther

Preferred times for your meetings

MorningAfternoonEveningWeekendFlexible

Is there any other important information you would like to share with us?

Consent clauses for international patients

I consent to the processing of my personal data by Cabinet CSMQ for the purpose of matching me with a qualified professional who meets my needs.I understand that the services do not replace medical or psychiatric care or emergency services.I have read and understand that if I am abroad, it is my responsibility to ensure that the services comply with my country’s laws.In case of emergency or crisis, I agree to immediately contact the emergency services in my country.I acknowledge that the laws of the Province of Quebec (Canada) shall apply.All our professionals have the appropriate degrees and are recognized by a professional order or certified association. They practise according to the ethical and legal standards of their field of practice.

Thank you for your trust. We will be in touch by email shortly.

An error occurred while sending. Please call us at 450-489-0882.

Book a Mental Health Consultation With Us

Triage Desk for New Patients

Bookings for Existing Patients

Confidential Admission Form

Consent clauses for international patients

Cabinet CSMQ

Got any questions or comments? Want to request a course to comply with Bill 27 or a consultation under the IVAC program?