Client Intake/Referral Form

Please fill out the below Intake form and a member of our team will get in touch with you. If you are experiencing problems with the form please email


How were you referred to us?*

Referee Information

Please enter client information below




*Please note that at this time, the doula/lactation consultant service will be offered virtually for those outside the Toronto area.
*Dental hygienists are currently available to clients in Toronto and surrounding areas only

Thank you for letting us know that you are seeking doula care and/or lactation support (IBCLC). Due to an increased demand we will no longer be providing full spectrum care and only one doula service can be booked. In addition, there are a few more questions that we need you to fill out to ensure you receive the best care possible. Please fill out the questions below, and click ‘Submit’ afterwards.

Consent to Tele-Rehabilitation

Tele-rehabilitation involves the use of electronic devices to enable 2-way communication between clients and their health practitioner at different locations for the purpose of diagnosis, therapy, follow-up and/or education. Transmitted information may include any of the following:

  • Client medical records
  • Live two-way audio and video
  • Client material such as exercise prescription and education materials may be sent to the clients via email upon request

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of client identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Expected Benefits

  • Improved access to healthcare and rehabilitation services by enabling a client to remain in their home or workplace for simple issues such as exercise prescription and education
  • More efficient evaluation and management

Possible Risks:

As with any rehabilitation procedure, there are potential risks associated with the use of tele-rehabilitation. These risks include, but are not limited to:

  • In rare case, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate rehabilitation decision making by the health practitioner and consultant(s);
  • Delays in rehabilitation evaluation and treatment could occur due to deficiencies or failures of the equipment;
  • In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information


  • Clients have the alternative to access in-person care at the clinic location within their health practitioner's clinical office hours.

By signing the form, I understand the following:

  1. I understand the purpose, risks, benefits, and alternatives of tele-rehabilitation.
  2. I understand that I have the opportunity to ask any questions or concerns that I may have prior to my rehabilitation session.
  3. I understand that I am responsible for immediately telling the therapist if I am having any discomfort or unusual symptoms during my tele-rehabilitation session.
  4. I understand that the laws that protect my privacy and the confidentiality of personal health information and medical information also apply to tele-rehabilitation, and that no information obtained in the use of tele-rehabilitation which identifies me will be disclosed to researchers or other entities without my consent.
  5. I understand that I have the right to withhold or withdraw my consent to the use of tele-rehabilitation in the course of my care at any time, without affecting my right to future care or treatment.
  6. I understand that I may choose to make an in-person appointment at any time (booked within your practitioner's clinical office hours).
  7. I understand that my health practitioner may recommend I schedule an in-person appointment to address issues that cannot be adequately addressed through tele-rehabilitation.
  8. I understand that tele-rehabilitation involves encrypted electronic communication of my personal medical information.
  9. I understand that I may expect the anticipated benefits from the use of tele-rehabilitation in my care, but that no results can be guaranteed or assured.

Local Emergency Number: Your safety is our primary concern and as a tele-rehabilitation client, you may live anywhere in Ontario. Below are the local York Region Emergency Numbers:

Emergency (Fire/Medical/Police): 9-1-1 York Region Paramedics: 1.877.800.7924 Richmond Hill Fire Services: 905.883.5444 York Region Police 1.866.876.5423

Should you be outside of the York Region area, please provide your therapist with your local first responder emergency numbers (not 9-1-1). This best ensures your safety should anything happen while on a tele-rehabilitation call with your therapist.

Thank you! Your submission has been received!
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