Services - Aviva Mental Health Services

Applicant Information

Full Name *

Age *

Date of Birth *

Gender *

Male Female Others

Address *

City *

State *

ZIP / Postal Code *

Country *

Email Address *

Contact Number *

Emergency Contact

Name *

Contact Number *

Relationship to Applicant *

Family Doctor

Doctor's Name *

Doctor's Contact Number *

Doctor's Address *

Explain Current Problem *

Previous Services & Medication

Have you taken any related services anywhere? *

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How May We Contact You?

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Please select at least one contact method.

Choose Service

Initial Bio-psychosocial$100 Initial Psych Assessment$150 Individual Psychotherapy (45 mins)$50 Individual Psychotherapy (60 mins)$60 Family/Couples Psychotherapy$80 Pharmacological Management$70 Custom payment amount *By prior approval only

* Custom amounts are to be used only after consultation and confirmation by the Director, Ms. Suzie Charles.

Please refer to the Service Description PDF for details.

Selected service amount (informational only)

This form submits a booking request only. No payment is collected on this page.

Please submit only information you are comfortable sharing through this form. This form does not provide emergency support.