Consultation Request Form

Welcome from Simon at Discovery Counselling & Mediation. Kindly fill out this form to complete your request for a 20-minute free discovery call.

You can expect to hear back from Simon within 48 hours via email. The discovery call will be held via our private and secure video portal.
Name

Preferred NameLast Name
Email
example@example.com
Phone Number (optional)
Please enter a valid phone number.
Service of Interest

PsychotherapyMediationCoachingPsychedelic SupportOther

Please list a few preferred times for our discovery call (Times are listed in EST).

You are invited to share a few words about your hopes and intentions for working together.
Should be Empty:

Welcome from Simon at Discovery Counselling & Mediation. Kindly fill out this form to complete your request for a 20-minute free discovery call.