Booking Form
1:1 Art-Based Wellness
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Can a message be left at this number?
*
Yes
No
Youth's Name (First & Last) and Age - If Applicable
What offering are you interested in?
*
Please Select
Express & Release
Art-Based Practice
Honouring Grief & Loss
Curated Mindful Art
Personalized Wellness
Are is there anything specific you'd like to explore during our time together? (burn out, stress, anxiety, general overwhelm, etc)
*
What is your hope for our time together?
*
CONFIDENTAILITY: All work with Lines That Bloom is confidential. Confidentiality is not held in situations that indicate you or someone else is at risk of being harmed.
*
Yes, I have read and understand the above information regarding Confidentaility.
No, I have further questions and clarification I'd like to discuss.
SCOPE OF PRACTICE: Lines That Bloom is wellness based care that does not include counselling or art therapy. If a situation arose outside the scope of practice you will be referred to additional or alternate service.
*
Yes, I have read and understand the above information regarding Scope of Practice.
No, I have further questions and clarification I'd like to discuss.
Would you like to be added to the email list and receive a Free art-based creative wellness guide and exclusive content?
*
Yes
No
Additional Comments
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