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First Name

Last Name

Email Address

Phone Number

Counsellor Preference

Can we leave a voicemail at this number? Can we leave a voicemail at this number? Yes No

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

Location Preference Location Preference Vancouver Ladner

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

What day(s) of the week are you available? (Please check all that apply) What day(s) of the week are you available? (Please check all that apply) Monday Tuesday Wednesday Thursday Friday Saturday (limited availability)

Subject

Message - **Please do not enter confidential information here as this is not a secure form. We will be glad to get specifics from you over the phone.**

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Please note: This form is not a secure form, please do not enter confidential information here. We will be glad to get specific information from you over the phone to ensure a good referral to our clinicians.