Full Name
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First Name
Last Name
Email Address
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example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
What would you like support with right now?
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Sessions are currently virtual. Does that work for you?
Yes, virtual works for me
I have questions about virtual counselling
I'd prefer in-person if that becomes available
Which days are you available?
Monday
Wednesday
Saturday
What times usually work best for you?
Mornings
Afternoons
Evenings
I'm flexible
How did you hear about me?
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Referral from a friend or family member
Google search
Psychology today
Referral from another therapist
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