Sapling Service Request Form (Adult)

Difficulty with organization, time management, or attention (ADHD, executive functioning challenges)

Sensory sensitivities (noise, light, textures, environments)

Fatigue, low energy, or difficulty keeping up with daily routines

Challenges with activities of daily living (e.g., meal prep, personal care, home tasks)

Struggles with motivation or feeling “stuck” in routines

Emotional & Mental Health

Parenting & Family Life

Prenatal or postnatal anxiety/depression

Challenges adjusting to parenthood (matrescence, identity shifts)

Struggles with balancing caregiving, work, and personal needs

Parenting stress or uncertainty about how to support your child’s needs

Relationship challenges with children (communication, co-regulation, attachment concerns)

Relationships & Social Connections

Physical Health & Wellbeing

Neurodivergence & Identity

Exploring or living with ADHD, autism, or other neurodivergence

Needing strategies for sensory regulation, routines, or executive functioning

Support with advocacy, accommodations, or navigating systems (school, work, healthcare)

Exploring aspects of identity (gender, sexual orientation, cultural belonging)

Please list any medical conditions, including developmental, neurological, physical, sensory, orthopedic, or other relevant conditions. If applicable, include any diagnoses related to learning, emotional regulation, or feeding challenges.

Are you currently experiencing any of the following? (check all that apply)

Mental Health & Emotional Safety

I am experiencing frequent thoughts of harming myself

I have a current plan or intent to harm myself

I am experiencing frequent thoughts of harming others

I have a current plan or intent to harm others

I often feel unable to manage overwhelming emotions or impulses

I have recently experienced major loss, trauma, grief and/or crisis

None of the above

Safety in Relationships & Home Life

Substance Use & Coping Strategies

Health & Physical Risks

Parenting & Perinatal Risks

I am experiencing prenatal or postpartum depression, anxiety, or intrusive thoughts

I am struggling with bonding or connecting with my baby/child

I am feeling unable to meet my child’s needs or keep them safe

I am worried about my child’s safety or wellbeing due to my own stress, health, or circumstances

None of the above

IMPORTANT NOTICE!

If you are experiencing suicidal thoughts, feel unsafe, or are in immediate danger, please seek support right away by contacting your primary care provider, calling 911 (or your local emergency number), or going to the nearest emergency department. You can also access immediate support through crisis services. These services are confidential, free, and available 24/7.

Crisis & Immediate Support Resources (Canada)

Suicide & Mental Health

Talk Suicide Canada: 1-833-456-4566 (24/7) – text 45645 from 4 PM–12 AM ET
Crisis Text Line: Text HOME to 686868 (24/7)
Kids Help Phone (for young adults, teens, parents): 1-800-668-6868 or text CONNECT to 686868

Domestic Violence / Safety Concerns

ShelterSafe (Canada-wide directory of shelters and support): https://www.sheltersafe.ca
Canada Victim Services: 1-866-234-2345 (varies by province)

Substance Use & Addiction

ConnexOntario (information and referral for mental health & addictions in Ontario): 1-866-531-2600
Hope for Wellness Help Line (Indigenous support): 1-855-242-3310

Immediate Emergency

Police / Emergency Services: 911

Please select all the professionals who are currently part of your circle of care:

Feel free to share any details, special requests, preferences, or questions that haven’t been covered in this form. This might include:

Specific goals or concerns
Cultural or language considerations
Preferred clinician characteristics
Scheduling needs or barriers to accessing services
Anything else that would help us support you or your child

We're here to listen and tailor our approach to best support your journey.

Thank you for completing this questionnaire.

By submitting this form, you will be added to our waitlist for the requested services. We will review your responses and connect with you when availability opens up.

If you have any questions or urgent concerns in the meantime, please do not hesitate to reach out to us at welcome@saplingtherapy.ca.

We truly appreciate your time and look forward to supporting you as part of your circle of care.

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