1 2 3 4 5 6 7 8 9 10 11 12 If you would like to request an appointment with one of our therapists, please fill out the following questionnaire to help us assess your needs. Completing this form does not guarantee that you will receive treatment. FUNDING SOURCE Funding Source * Private Pay Sensitive Claims (ACC) PRIVATE PAY Private Consultation Fees are charged at an hourly rate and are dependent on the profession of the therapist. Psychologist $120 - $160 Psychotherapist $100 - $140 Counsellor / Arts Therapist $80 - $130 Rates are GST exclusive CAPTCHAWe'd like to prevent automated spam submissions. Please demonstrate that your are not a robot.