Request an Appointment with a Counsellor Your Name (required) Date of Birth (required) Your Email Your Phone Number Can we leave a voicemail message on the number that you have provided? YESNO Three main concerns for which you’re seeking therapy or spiritual direction. I am looking to have therapy covered by benefits. yesnoIf possible, but not required *All clients must check with their benefits provider directly on the exact credentials required in order to be covered. Do you prefer a male or female therapist? —Please choose an option—MaleFemaleDoesn't Matter Did you have a preferred location? —Please choose an option—Kensington (NW)Inglewood (SE)South (SE)Silver Springs (Cathy)N/A Preferred mode of Counselling: In office Telephone Counselling Online Counselling Did you have a particular Therapist in mind? Soonest AvailableJennifer Dawn Watts (Telephone/Online)Cathy McCurdy (Silver Springs)Karla Reimer (Inglewood)Aziza Giga-Hirji (Telephone/Online)Kaylee Garside (Telephone/Online)Steven Ngu (South)Katherine Jarrell (Telephone/Online)Heather Nolin (Kensington and South)Beverly Reed (Kensington)Carrie-Lee Gibson (South)Natalie Draycott (South)Anya Stang (Kensington)Melissa Cavanagh (Kensington)Shannon Baustad (Telephone/Online)Celeste Rodrigues-Forbes (South)Kaitlyn Barnett (Telephone/Online)Anne Sureshkumar (Kensington)Daria Nechaieva (South)Marissa Whalley (Kensington) If that therapist is unavailable, did you have a second choice? Soonest AvailableJennifer Dawn Watts (Telephone/Online)Cathy McCurdy (Silver Springs)Karla Reimer (Inglewood)Aziza Giga-Hirji (Telephone/Online)Kaylee Garside (Telephone/Online)Steven Ngu (South)Katherine Jarrell (Telephone/Online)Heather Nolin (Kensington and South)Beverly Reed (Kensington)Carrie-Lee Gibson (South)Natalie Draycott (South)Anya Stang (Kensington)Melissa Cavanagh (Kensington)Shannon Baustad (Telephone/Online)Celeste Rodrigues-Forbes (South)Kaitlyn Barnett (Telephone/Online)Anne Sureshkumar (Kensington)Daria Nechaieva (South)Marissa Whalley (Kensington) Days/Times Available: Weekday Daytime Evening Saturday All of The Above Comments on Availability: Book an Appointment or Start with a 20 Minute Consult: I would like to start with a free 20 minute consult to get to know my therapist & their approach to treatment I would like to get started on treatment as soon as possible with a full one hour appointment Have you worked with one of our therapists before? Yes No If so, please list your previous therapists. Your quality of service is important to us. Our owner Jennifer Dawn Watts or Director Steven Ngu may follow-up to request for your feedback. Do you consent to receiving contact from either Jennifer or Steven? YesNo Anything else you’d like us to know? Please click Send and wait for the “Your Message Was Sent Successfully” message to show up below. This will ensure we receive your form. Thanks! *Information transmitted via internet may not be secure and by participating, you hereby acknowledge, and understand, and agree to the inherent risks and limitations to confidentiality associated with internet use and telepsychology (e.g., risk of public discovery, internet history discovered by others, possibility of hackers, etc). If you are not comfortable submitting this document online, please print off this page and submit a hard copy to your counsellor during your initial meeting.* Δ