Dare to Heal...Let's Talk: Telephone Consultation Screening Form  
 After you complete this form you will be notified via email - a confirmation of your scheduled call time. Please be sure to provide your name, contact number and email address on the next screen in order for us to make contact. Looking forward to speaking with you soon!  
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Email *
Dear Client, to get started, please provide your first and last name:   *
Dear Client, please provide below your best TELEPHONE NUMBER to be contacted on so that we can touch base with you about setting up your complimentary call.    *
Dear Client, please provide below your best EMAIL ADDRESS to be contacted on so that we can touch base with you about setting up your complimentary call.    *
How did you hear about Dare to Heal…Let’s Talk? *
Which type(s) of counselling are you interested in pursuing? (Check all that apply) *
Required
Which of the following service(s) do you have extended health benefit coverage for? *
Required
Please briefly describe a) the presenting concern(s) for which you are seeking services and list your top 3 goals; b) What you are looking to get out of counselling; and c) what are you hoping would be different when you complete therapy?   *
Starting off, it is recommended that sessions occur weekly until you start to meet your goals, and then tapering sessions to once every other week. Are you able to commit to weekly sessions at this time? *
Please indicate your availability for a 15-minute consultation phone call (check all that apply):   *
Required

Please indicate your availability for therapy sessions (check all that apply): 

 *
  *Please note the below service days are standard offerings, additional days are available periodically throughout the year* Choose as many as you like:  
Required

Please share any questions or concerns you have about counselling so that we can address them during your consultation call. 

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