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important relationships.

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Counselling Request Form

    Please provide your name (required)

    Please provide your email address (required):

    Please provide your phone number (required):

    All information provided below will be forwarded to the counsellor/group administrator of your choice and treated as highly confidential and private.

    Are you seeking: (required);

    Select your preference:

    or Choose a DFR Counsellor below:

    Briefly describe your situation and concerns - 200 words or less (required):

    Please provide your age category or the category of the one who will be receiving care:

    Best way to contact you: (required);

    When is the best time to contact you? (required)

    What days and times would work best for counselling appointments? (required)

    Preferred Appointment Modality: (required);

    Office Preference if selected in-person: (required);

    How did you hear about us? (required)