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Counselling Intake Form
First name
*
Last name
*
Email
*
Phone
*
Pronouns
Date of Birth
Is this counselling for you or a child/youth?
What are you looking for support in? (check all that applies)
Child therapy
Substance Use
Abuse
Divorce/Separation
Intergenerational Trauma
Grief
Mental Health
Stress
What is your preference for sessions?
In-person
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Doesn't matter
Submit
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