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Markham

Concord / Vaughan

Virtual Across Ontario

Basic Information

Full Name

Phone Number

Email

Logistics & Access

Your preferred location * Required

Vaughan

Markham

Virtual

What is your budget?

Therapy Details

What type of Therapy are you seeking? * Required

Family

Individual

Couples

Unsure

How did you hear about us?

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Doctor or Healthcare Practioner

Family or Friend

Other

Why are you seeking Therapy?

What kind of Therapist would you prefer to work with?

I consent to being contacted to coordinate my free 15-minute consultation and understand this form does not establish a therapist-client relationship.

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