Service Request

Getting Started

Welcome, and thank you for reaching out!

This brief form is designed to:

Help you explore the services available at OICBT.
Better understand your goals, needs, and preferences.
Allow our Care Coordination Team to connect you with the therapist or service that best fits your situation.

Please answer each question in a way that reflects your own experiences — there are no right or wrong answers.

Estimated time to complete survey: 5-10 minutes, depending on the services selected.

At the end of the form, you will be provided with options for next steps.

All information shared is kept strictly confidential and handled in accordance with applicable privacy laws.

I am making this request

For myself (self-referral)

For a family member, friend, loved one

As a health care provider for a client

Client date of birth

all the calculations

[show-referral-source-details]

[hardstopcalc]

age calculation

[age-years]

service eligibility calculation

[eligibility-adult-therapy]

[eligibility-child-therapy]

[eligibility-adult-assessment]

[eligibility-child-assessment]

[eligibility-couples-therapy]

[eligibility-group-adhd]

[eligibility-group-mindfulness]

[eligibility-group-coping]

[eligibility-high-intensity]

[eligibility-dbt]

requested service calculation

[requested-adult-therapy]

[requested-child-therapy]

[requested-adult-assessment]

[requested-child-assessment]

[requested-couples-therapy]

[requested-group-therapy]

[requested-dbt]

requested service maths 1

[math-adult-therapy]

[math-child-therapy]

[math-adult-assessment]

[math-child-assessment]

[math-couples-therapy]

[math-group-therapy-adhd]

[math-group-therapy-mindfulness]

[math-group-therapy-coping]

[math-high-intensity]

[math-dbt]

number-of-services-selected

0 + 0 + 0 + 0 + 0 + 0 + 0 + 0 + 0 + 0

requested service maths 2

[math-adult-therapy-2]

[math-child-therapy-2]

[math-adult-assessment-2]

[math-child-assessment-2]

[math-couples-therapy-2]

[math-group-therapy-adhd-2]

[math-group-therapy-mindfulness-2]

[math-group-therapy-coping-2]

[math-high-intensity-2]

[math-dbt-2]

number-of-services-selected-2

0 + 0 + 0 + 0 + 0 + 0 + 0 + 0 + 0 + 0

service selection user can proceed calc

[service-selection-user-can-proceed]