Contact Email: firstname.lastname@example.org Phone: 1 (866) 295-0551 FollowFollowFollow Fill out the brief questionnaire below to help us understand what you’re looking for. We will be in touch with you within 48 hours. We’re thankful for your bravery and excited for all you may achieve with us! Name Email Phone Are you seeking counselling for yourself or someone else?Individual (for myself)For someone else Reason for seeking services Has this person had counselling in the past?YesNo If yes, specify the outcome and if it was positive or negative: Location (City/Town for timezone calculation) Referred by Are we permitted to send texts and voicemail messages?YesNo Counsellor Gender PreferenceMaleFemaleNo Preference What approach do you prefer from your counsellor?Softer approachFirmer approachNo Preference Anticipated Barriers to Counselling (if applicable) Preferred time of Appointment Health Benefits Coverage and Details How much are you comfortable paying per session? CaptchaPlease enter the text visible in the above image. Time is Up!