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Request an Appointment with a Counsellor





Please note: 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.

Your Name (required)

Your Email (required)

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.

I am hoping to qualify for sliding scale fees?
yesnoIf possible, but not required

Do you prefer a male or female therapist?

Did you have a preferred location?

Did you have a particular Therapist in mind?

If that therapist is unavailable, did you have a second choice?

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

Your quality of service is important to us. Our owner Jennifer Dawn Watts may follow-up to request for your feedback. Do you consent to receiving contact from Jennifer?
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 beside the Send button. This will ensure we receive your form. Thanks!