Register Online - Dalton Associates

By using this contact form, you acknowledge that your information is retained for 60 days and is emailed to our Client Care Team for follow up. Email is not a secure form of communication. If you would prefer to speak with our Client Care Team, please call 1-888-245-5516.

Name*

First

Last
Gender*
Date of Birth*

MM slash DD slash YYYY
Are the Services for a Child?*
Name of Child

First

Last
Child's Gender
Child's Date of Birth

MM slash DD slash YYYY
Name of Partner (If Partner is Attending)

First

Last
Partner's Date of Birth (If Partner is Attending)

MM slash DD slash YYYY
Street Address*
City*
Province*
Postal Code*
Primary Phone*
Alternate Phone
Reason for Counselling*
Would You Be Submitting a Claim for Reimbursement Through Your Extended Health Benefits?*
What is the Name of the Provider of Your Extended Health Benefits?

Please let us know which providers you have coverage for (Registered Psychotherapist, Registered Social Worker, and/or Registered Psychologist) so we can make sure to match you with the proper therapist.
How Did You Hear About Dalton Associates?

If you were referred by your family doctor, please include his/her name.
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