One of the fastest ways to connect with us is through email. Please use this form so that we can meet your individual needs quickly.

After receiving your information, our office manager will follow up with you directly to answer all your questions and propose appointment spots.

  • Have you checked if your insurance policy reimburses you for professional services?
  • Look to see if there is an annual limit, per person limit, and/or per session limit.
  • Check when your insurance renews (January versus June, for example)

Please fill in the information below, and we will contact you as quickly as possible:

Your Name*

Your Email*


Your Phone Number*

I am seeking services for...*

Date of Birth (YYYY-MM-DD)*

Primary language spoken at home*

Other languages spoken at home

Services requested*

Primary concern*

Previous professional services?*

Previous professional reports?*

Service delivery options*

For children only:

Name of child's School/Daycare

Languages Spoken at School/Daycare

Do both parents live together]

Parent/Guardian/Mother’s first and last name

Parent/Guardian/Mother’s email address

Parent/Guardian/Father’s first and last name

Parent/Guardian/Father’s email address

Any additional information you wish to share

Two Clinic Locations

SouthWest One
175 avenue Stillview, Suite #230

6359 Jean-Talon, Suite #203
St. Leonard, Quebec, H1S 3E7

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