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Child & Youth Programs
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Child & Youth Programs
Parent Programs
Professional Workshops
Counselling
Early Learning Centres
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Child & Youth Programs
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Counselling
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Request Appointment
Type of Counselling
Counselling Type
*
Individual, Couple, & Family
Youth
Play Based Therapy
This appointment request is for:
*
An Individual
A Couple
A Family
Client (or Parent or Guardian of Minor Client)
What is your name?
*
First
Last
What best describes your gender?
*
Male
Female
Non-binary
A gender not listed here (I'll enter it below)
Unsure of how to describe myself
Prefer not to say
How do you describe your gender?
*
What is your date of birth?
Year
2025
2024
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What is your address?
Street Address
City
Province
Postal Code
Contact Information
What is your email address?
*
Is it okay to email you at this address?
*
Yes
No
What is your primary phone number?
*
What type of phone if your primary?
Home
Work
Cell
Is it okay to leave you a message on this phone?
*
Yes
No
What is your secondary phone number, if one exists?
What type of phone is your secondary?
*
Home
Work
Cell
Is it okay to leave you a message on this phone?
*
Yes
No
Family Members
Will additional family members be joining the session?
*
Yes
No
Please list them below:
*
Name
Date of birth
Relationship to you
Insurance
What employee assistance program do you have?
GSCS
Other (I'll list it below)
No EAP
Please enter your employee assistance program:
*
What type of insurance do you have?
Blue Cross
Manulife
No Insurance
Other (I'll list it below)
Please enter your insurance provider:
*
What kind of appointment do you prefer?
*
Phone
Zoom
In Person
Comments
This field is for validation purposes and should be left unchanged.