Secure Contact Form

Name of the Person Completing the Form

First Name & Last Name

Email Address

Phone Number

Which therapist would you like to work with?

We suggest reviewing our Team Page on our Website & selecting 2-3 who might read as a good fit.

Location Preference: Check all that apply.

Bedford only

Dartmouth only

Either Bedford or Dartmouth

Virtual only

Virtual as an option

Are you inquiring about individual Adult Therapy? Check One

Young Adult 19-24 years

Adult 25+ years

Senior 65+ years

Are you inquiring about Couples Counselling? Check One

Yes

Yes, we require a CNM trained therapist

Are you inquiring about Family Therapy? Check One

Family members adults only

Family members with under 16 years old

Note: Child Therapy is Different than Family Therapy- See Below

Family Therapy Only- List who will be attending & ages

Family Therapy Only- Briefly explain the reason for therapy

Are you inquiring about Individual Therapy for a Child? The initial session will be booked with the parents only, followed by individual sessions for your child only.

Child 5-9 years

Child 10-12 years

Are you inquiring about Individual Therapy for a Teen?

Teen 13-15 years

Teen 16-18 years

Parental Consent for Minors Clinic Policy:

ML family Counselling provides therapeutic services to minors under 16 years of age as long as we have signed consent from the parent(s) or legal guardian(s) as well as assent of the child.

There are times we require both parents signed consent and there are times we require only one parent’s signed consent.

I give permission to leave a voicemail.

Yes

How did you hear about us?

Doctor, Counsellor, Lawyer, or Other Professional

Internet Search

Friend or Family Member

Social Media

Any other important information -brief 2-3 sentences

Your information will be encrypted.