CONTACT US

Your Name*

Your Email*

Your Phone

Inquiring as*
---ClientHealth care professionalFamily/Friend of client

Service requested*
---Consultation or AssessmentIndividual Therapy (Adult – 18 years+)Individual Therapy (Adolescent – 13-18 years)Individual Therapy (Child <12 years)Couples TherapyFamily TherapyGroup TherapyProfessional TrainingOther

Message

Can we leave a message on your phone?*
---YesNo

Consent* for Email Communication**. By checking this box, I confirm that I have read and agree to these terms.

* Required

** I wish to communicate with my care provider via email. I acknowledge and understand that these email messages are not encrypted and that the Centre for MindBody Health cannot guarantee the security of messages that I send or receive from my care provider.

I agree not to use email to communicate emergency or urgent health matters.

I acknowledge that at any time, I or my care provider can decide that we no longer wish to communicate through email. If I decide to stop communication through email, I agree to inform my care provider in writing or at my next appointment.