Brook Harbor Guidance & Support Online Services

Brook Harbor Guidance & Support Online Services – Registration Form

Sign up to access guidance and support services. Please complete the form below to register.
Personal Information

Please provide your details below.
Full Name*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
City / Province
Individual Health SupportGroup SupportPre-marital Support Session for a coupleDementia Care SupportMental Wellness SupportEmotional SupportOther
If Other, Please Specify
Under 1818–2425–3435–4445–5455–6465+
In-personOnline (Video Call)Phone Call
10:00am – 10:45am11:00am – 11:45am1:00pm – 1:45pm2:00pm – 2:45pm4:00pm – 4:45pm7:00pm – 7:45pm
If Other, Please Specify
Bank TransferE-transferCash (in person)Other
If you selected 'Other' for Payment Method, please specify:
Payment Information: Please send your session fee (s) to the following bank details:

RBC ACCOUNT NO: 02432-1014380

INTERAC DETAILS: Brookharborcareservices@gmail.com

ROYAL BANK OF CANADA

Include your full name as payment reference. Confirmation will be sent upon receipt. (This section is for informational purposes only and cannot be edited.)
I understand that Brook Harbor Care Services provides supportive, non-clinical guidance under PSW scope—not psychotherapy or clinical counselling.
Signature*
Date*

MonthDayYear
These services do not replace a doctor, psychologist, therapist, or clinical counsellor.No diagnosis or mental health treatment is provided.PSW support is strictly non-clinical emotional and personal guidance.Severe mental health cases will be referred to licensed professionals.
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Brook Harbor Guidance & Support Online Services – Registration Form

Personal Information