Form
Faye Shedletzky Align Within Therapy Inquiry Form
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Date of Birth
-
Month
-
Day
Year
Date
Did anyone refer you to this service?
Yes
No
If yes, who referred you?
If you found me through an internet search, was there something that resonated with you in particular?
What has led you to seek support at this time?
How long have you been having these challenges?
How do these challenges affect you?
Have you done counselling before?
Yes
No
What would you like to gain from counselling at this time?
Where do you live (city/province)?
Are you interested in online or in person counselling?
online
in person
both
Please list preferred days of the week and times in the next 2 weeks to book an initial consult (or list any restrictions on times to book)
Would you prefer to book an initial consult by phone or video?
phone
video
Are you currently a student at Vancouver Island University (I work there part time so if you are, we need to discuss further)?
Yes
No
Do you have any specific questions for me before beginning our work together?
Submit
Should be Empty: