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. I am looking for a sliding fee scale. yesnoIf possible, but not required 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)Varsity Estates (Anya)N/A Preferred mode of Counselling: In office Telephone Counselling Online Counselling Did you have a particular therapist in mind? Soonest AvailableJennifer Dawn Watts (Inglewood/Online)Cathy McCurdy (Silver Springs/Online)Aziza Giga-Hirji (Online)Katherine Jarrell (Inglewood/Kensington)Heather Nolin (Kensington)Beverly Reed (Kensington)Carrie-Lee Gibson (South)Anya Stang (Varsity Estates)Shannon Baustad (Telephone/Online)Celeste Rodrigues-Forbes (South)Daria Nechaieva (South)Jacqueline Van Starkenburg (Kensington/South)Ian Seitz (South)Khobi Attai (Kensington)Judy Cho (South/Kensington)Rochelle Hughes If that therapist is unavailable, do you have a second choice? Soonest AvailableJennifer Dawn Watts (Inglewood/Online)Cathy McCurdy (Silver Springs/Online)Aziza Giga-Hirji (Online)Katherine Jarrell (Inglewood/Kensington)Heather Nolin (Kensington)Beverly Reed (Kensington)Carrie-Lee Gibson (South)Anya Stang (Varsity Estates)Shannon Baustad (Telephone/Online)Celeste Rodrigues-Forbes (South)Daria Nechaieva (South)Jacqueline Van Starkenburg (Kensington/South)Ian Seitz (South)Khobi Attai (Kensington)Judy Cho (South/Kensington)Rochelle Hughes 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 treatmentI 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? YesNo If so, please list your previous therapists. 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 either Jennifer? YesNo We’re really glad you found us and hope to help others who need our services. Can you tell us how you heard about Living Well? Google search on first page of Google Google Reviews (Google Maps) Psychology Today ad Sign at Douglasdale location Theravive Instagram Facebook Twitter/X Former client referral (Counsellor referred to) Doctor referral Church referral Other 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