Request Your First Counselling Session

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Client Name(s):

First Name(s):

Last Name(s):

Preferred Method of Contact:

Telephone
Please note that we appear as “Private Caller” on call displays.

Email
Please note that email correspondence is non-secure.

Counselling Service:

Personal Counselling for Adults (Age 16 and Over)Personal Counselling for Youth (12 - 16)Couple CounsellingFamily Counselling

Please tell us about your counselling needs:

(Please note that if you do not feel comfortable describing your counselling needs, you may leave this section blank.)

Which therapist would you prefer to see?

OR

Any female therapistAny male therapistAny therapist

What is your scheduling availability?

In Crisis

X