Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. - Step 1 of 5Name *FirstLastEmail * to a do Phone *NextGender *MaleFemaleNon-BinaryWho are you seeking counselling services for? *MyselfChild (0-12 years)Youth (13-17)OtherNextIn which province do you reside ? *Nova ScotiaNew BrunswickWhat are you looking for? *In Person - Dartmouth, NSVirtualBoth. Do you have a preferred day of the week for your sessions? (ie: Monday AM, Tuesday PM, etc ) Do you have a preferred time of day for your sessions? (Early morning, afternoon, evening)NextAre you seeking any of the following ? *Eye Movement Desensitization and Reprocessing (EMDR)Eating Disorder RelatedAddictions / Substance UseCouples / Relationship FocusFamily CounsellingFerility RelatedI'm not sure / Not ListedWhat are you looking to speak to a Therapist about? *NextYour match information will be sent to you via email. Should our Client Coordinators have any questions, when would be the best time to reach you? *9 AM to NoonNoon to 4 PM4 PM to 6 PM6 PM to 7 PMAuthorization *Consent and AgreementI consent to being contacted by a Client Services Coordinator who will match me with a therapist based on the information I have provided. I understand that Your Counselling Ltd. is a fee-for-service clinic, and I will be informed of the applicable fees once I have been matched with a therapist.Signature * Clear Signature Request Matching
