Name *

First Name

Last Name

Phone *

(###)

###

####

SMS/Text Message Consent *

Message frequency varies and may include appointment reminders, or service information. Message and data rates may apply. Opt out at any time by replying 'stop' or 'unsubscribe'

Yes, I agree to receive text messages from Parkland Psychology & Wellness at the phone number listed above.

No, I do not want to receive text messages from Parkland Psychology & Wellness.

Appointment Availability *

Mornings Between 9 :30 am - Noon

Afternoons Between 1:00 pm - 5:00 pm

Evenings Between 6:00 pm - 8:00 pm

Appointment type: *

In Person

Virtual

Either

Are you looking to use insurance? *

Yes

No

Are you open to working with a graduate student counsellor? *

Yes

No

Undecided

What counsellor qualities are you seeking? Select all that apply. *

Warm & Understanding

Direct & Engaged

Solution-Focused

Compassionate & Sensitive

Sense of Humour & Outgoing

Practical