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Name

Email address

Phone number

In review of our website, please list the therapist(s) you are interested in working with.

Some of our therapists have waitlists it would be helpful if you suggested 2 or 3 options you think would be a good fit.

Which office could you attend? Check all that apply.

Bedford

Dartmouth

I'm Flexible, Either Bedford or Dartmouth

Remote Only

What type of therapy are you inquiring about? Check one

Individual Therapy

Couples or Partners Therapy

Family Therapy

Who is therapy for? Check one

Child 3-5 years old

Child 6-9 years old

Child 10-12 years old

Teens 13-15 years old

Teens 16-18 years old

Adult Individual

Partners in Relationship

Family members including minors

Family members adults only

Main reason(s) for seeking therapy Choose only 3

Anxiety and Stress

Confidence, Self Esteem and Support

Depression

Grief and Loss

Chronic Pain or Illness

Relationship Issues

Trauma and PTSD

Life Transitions

Identity Exploration

General Mental Health Challenges

ADHD or ASD

School Concerns

Behaviour Concerns

Emotional Regulation

Anger Issues

Sex Therapy

Substance Use

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Yes, you can leave a voicemail.

No, do not leave a voicemail.

How did you hear about us?

Doctor, Counsellor, Lawyer, or Other Professional

Internet Search

Friend or Family Member

Social Media

Email address

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