Service Request

SERVICE REQUEST
Please fill out the following service request and press "Submit" at the bottom of the form. We will receive your request and do our best to connect with you within 24-48 hours.
Personal Information and Contact Details
Name

First NameLast Name
Date of Birth
Gender
If you are filling out this form for someone else, please fill out the following information.

Your Full NameRelationship to person needing servicesYour Phone Number
Address

Street Address

Street Address Line 2

City

Postal / Zip Code
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Preferred method of contact?
May we leave a message identifying ourselves from Serenity Shores?
Presenting Concern(s):
Description of presenting issue(s):
Additional Information
Are you open to working with a Master’s level student counsellor? (No cost)
Should be Empty:

SERVICE REQUEST