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Would you like to see someone in the office or by secure video (telehealth)? Would you like to see someone in the office or by secure video (telehealth)? In the office By secure telehealth Not sure

What time(s) of the day are preferable? (Please check all that apply) What time(s) of the day are preferable? (Please check all that apply) Morning Afternoon Evening

What day(s) of the week are preferable? (Please check all that apply) What day(s) of the week are preferable? (Please check all that apply) Monday Tuesday Wednesday Thursday Friday

What services are you interested in? (Please check all that apply) What services are you interested in? (Please check all that apply) Counselling 1:1 DBT Therapy Neurofeedback Registered Massage Therapy Adult DBT Group Therapeutic Arts Sessions Professional Training

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