Home
Services
About Brandy
How It Works
Methods
Apply For A Free Consult
Home
Services
About Brandy
How It Works
Methods
Apply For A Free Consult
REACH OUT PRIVATE 1-1 INTAKE FORM
Name
*
First Name
Last Name
Email
*
Phone
(###)
###
####
Which Province/State do you currently reside in?
*
Preferred Contact Method
*
Email
Phone
Age
*
Please provide an emergency contact person (must be 18 years or older)
*
What brings you to seek support at this time?
*
Are you currently participating in therapy or counseling?
*
What are your main goals for these sessions?
*
Any specific concerns or topics you would like to address?
*
Preferred Days and Times for Sessions
Is there anything else you would like me to know?
How did you hear about Reach Out?
Friend/Family
Discord
Facebook
Search Engine (Google)
Other
Thank you!