New Potential Client Inquiry
Please enter a brief synopsis of answers below.
We will get back to you within 72 hours/3days (often much sooner than that!)
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Email *
Name *
Email *
Phone *
What is your preferred method of contact? *
Required
How would you like to receive therapy services? *
Availability for sessions
Thursday
Friday
Saturday
Morning (10-12)
Afternoon (12-4)
Evening (4-7)
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Date of Birth *
What mental health or physical disorder/illness diagnosis(es) do you self-identify with?
(You may have been diagnosed previously with depression but self-identify as having ADHD, or you may have "self-diagnosed" yourself as having Autism Spectrum Disorder.)
What are your main goals for therapy? *
How motivated are you to make changes in your life?
A copy of your responses will be emailed to the address you provided.
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