BOOK APPOINTMENT

Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Phone

(###)

###

####

Are you comfortable with us leaving a message with the phone number provided identifying ourselved as Helping to Reconnect Counselling Services?

Yes

No

Type of Concerns

ADHD

Anger Management

Anxiety

Burnout

Couples Therapy

Depression

Divorce Or Separation Adjustment

Emotional Eating Or Disordered Eating Patterns

Family Conflicts

Friendship Issues

Grief & Loss

Identity Exploration

Infertility

Major Life Changes

Negative Self-Talk

OCD

Postpartum

Procrastination & Motivation Struggles

Self-Esteem & Self-Worth Issues

Stress Management

Substance Use

Trauma

PTSD

Unresolved Childhood Trauma

Other (Please describe your type of concern in text box below)

Daily Availability (Check all that apply)

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Time Availability (Check all that apply)

Morning (8am - 10am)

Late Morning (10am - 12pm)

Mid-Day (12pm - 2pm)

Afternoon (2pm - 4pm)

Late Afternoon (4pm - 6pm)

Evening (6pm - 10pm)

Checkbox

By clicking this box, I acknowledge that I have read and agree to the terms and conditions, including the privacy policy. I consent to the collection and use of my personal information for the purposes of scheduling, communication, and service provision. I understand that my data will be kept confidential and will not be shared without my explicit consent, except as required by law.