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Counselling Referral Form
Your name will be added to the waitlist
Counselling fee: $50/session
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* Indicates required question
Email
*
Your email
Client surname
*
Your answer
Client First name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Client Age
*
Your answer
Parent/Guardian 1 (if under 18)
Your answer
Parent/Guardian 2 (if under 18)
Your answer
Home Address
Your answer
City
Your answer
Postal Code
Your answer
Primary Phone
*
Your answer
Can we leave a message?
*
Yes
No
Alternate Phone
Your answer
Can we leave a message?
Yes
No
Clear selection
Preferred Email address
*
Your answer
We may contact you initially by email. Do you consent to contact via the email address you entered above?
*
Yes
No
Requested Service
*
In-person counselling
Online counselling
No preference
The Department of Educational Psychology is an active research department, and we often have researchers looking for project participants. If you would like to be contacted, please select the box below.
Yes, I am willing to be contacted by the Department of Educational Psychology for possible future research project participation.
A copy of your responses will be emailed to the address you provided.
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