We’re here to support you! 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! Full Name Email Phone Are you seeking counselling for yourself or someone else? Individual (for myself) For someone else Reason for seeking services Have you (or the person you’re filling this out for) had counselling in the past? Yes No If yes, specify the outcome and if it was positive or negative: Location (City/Town for timezone calculation) Where did you hear about us? Are we permitted to send you text messages? Yes No Are we permitted to leave voicemail messages? Yes No Do you know anyone who is a current, or was a past, client of ours? Yes No Please share their name and if you know who they are working/worked with. *Please note this information helps us to prevent any conflict of interest when assigning clients to one of our counsellors. What approach do you prefer from your counsellor? Softer approach Firmer approach Somewhere in between No Preference Counsellor Gender Preference Male Female Non-binary No Preference Are there any barriers/reasons why you would not be able to attend sessions online? Yes No If yes, please let us know the reason below Preferred day(s) and time(s) of appointment. Please note that we cannot guarantee accommodation of this preference, but we will do our best! Honestly considering your budget, how much are you able to pay for counselling (per session)? Please review our cost structure for more information about these options. Time is Up! Time's up
