Pre-Screening Form
Please fill this form out in its entirety as it will aid both of us in the process of assessing if we may be a good therapeutic fit.

Thank you so very much in advance!
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First & Last Name *
Email Address *
Telephone Number *
I'm currently only working with clients who live in Barbados. Do you reside in Barbados? *
Birth Date *
MM
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DD
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YYYY
Gender *
Preferred Method of Contact - please note that you will be contacted by Wings of Grace Counselling via email in most circumstances. *
Which modality of therapy are you seeking? *
Primary Reason for Seeking Therapy - please select a maximum of 3 items. *
Required
Are you seeking to attend therapy voluntarily? *
Please scale your current willingness to attend therapy *
My operating hours are 11am-7pm. Do you have consistent availability between this time frame for the purpose of scheduling sessions? *
Preferred time to meet *
Preferred day to meet *
Are you able and willing to do sessions weekly? *
If you answered no to the question above, are you able and willing to do sessions bi-weekly? *
All sessions are done virtually via Zoom. Does this work well for you? *
If you answered no to the question above, would you like to receive 1-2 referrals for in-person therapy? *
How did you hear about us? *
I understand that completing this form does not guarantee a therapeutic relationship
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