Name (required)

First Name *

Last Name *

Email *

Phone *

Text messaging permission

Can we text message you at this number?

Select an option

Message

Are you interested in a specific type of therapy/s? If so, please list them.

Availability

Please tell us what your preferred days & times are for counselling sessions.

Session Type

Some of our counsellors offer both in office or virtual counselling sessions, several only offer virtual. To assist us in matching you with a counsellor please select your preference.

Virtual

No preference

In Office

Location Preference

Which location would you prefer?

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Counselling Coverage

Do you have counselling coverage through ICBC, CVAP, FNHA, or another provider? If so, please list.

Do you require a reduced rate?

Yes

No

Maybe

Student Counselling

Are you open to working with a student?

Yes

Unsure

No