Name *

First Name

Last Name

What is your Phone Number? *

(###)

###

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Would you prefer in-person counselling sessions only, online sessions only or is either ok? *

Online Only

In-Person Only

Either

Would you prefer to work with a female counsellor only, a male counsellor only or is either ok (we do not currently have someone on the team who identifies as non-binary)? *

Female Counsellor Only

Male Counsellor Only

Either is Okay