Accepting New Clients.

This form is not for health information, and I consent to my contact information being used to respond to my inquiry. My message will be sent to this clinic via unencrypted email. Do not include symptoms, diagnoses, medications, or other sensitive details.

Consent & Privacy Notice: By submitting this form, you acknowledge and agree to the following: The information you provide will be used to respond to your inquiry and, if applicable, to support the initiation of services at BelongSpace Counselling. Communication through this form and by email may not be fully secure, and confidentiality cannot be guaranteed. This form is intended for general inquiries only and is not appropriate for urgent or crisis situations. Submitting this form does not establish a therapeutic or clinical relationship. A therapeutic relationship begins only after a formal intake process and mutual agreement to proceed. Your personal information will be handled in accordance with applicable privacy legislation in Ontario, including the Personal Health Information Protection Act (PHIPA), and the professional standards of the Ontario College of Social Workers and Social Service Workers (OCSWSSW). By selecting “I’ve read and agree,” you confirm your understanding and consent to the above.