REACH Psychological Booking Form
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Email *
Are you the client? *
Client First Name *
Client Last Name *
Client Data of Birth (DOB) *
MM
/
DD
/
YYYY
Caregiver/Parent/Guardian name (if applicable)
Email *
Best Phone Number *
Are you looking for in-person or virtual services? *
What are you noticing and what is your biggest concern?

A note for counselling services: Please list the type of counselling support you want (no details). Examples: grief, anxiety, depression, trauma, relationships, etc.   *
I agree and understand the following:
  • By submitting this form, I authorize REACH Psychological Services to collect, use, and disclose my (or the referred individual’s) personal and health information (including name, contact details, date of birth, and referral reason) for the purpose of processing this referral, assigning an appropriate provider, and contacting me by phone, email, or text.
  • I understand REACH Psychological Services is not an emergency or crisis service. If I am in immediate danger, experiencing a crisis, or feel unsafe, I will call 911 immediately.
  • I understand the benefits (e.g. timely access to services) and the risks (e.g., potential privacy risks when communicating through phone, email, or text, which may not be fully secure). I understand this consent is voluntary and may be withdrawn at any time by emailing admin@reachpsychological.com.
  • If I am consenting on behalf of a minor or dependent, I confirm I am the legal guardian or an authorized representative
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