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By completing the following form, you will be on your way to participating in individual or group counselling services. All the information you send us will be private and confidential. Please complete the questions and tell us what you are looking for, and if possible, which program you wish to take. If you are unsure, you can request a general assessment. Note that all services have a cost – refer to the Fees and Payment page.

Individual and Group Anger Management services require a pre-payment for the assessment interview.

Someone from our office will contact you within five business days to arrange an appointment time.

Contact Information

Your Name:

Partner's Name (if requesting couples counselling):

Your Date of Birth (mm/yyyy):

Street Address:

City:

Province:

Postal Code:

Country:

Email:

Can we send you an email message?:

Home Phone:

Can we leave a message?:

Cell Phone:

Can we leave a message?:

Work Phone:

Can we leave a message?:

Emergency Contact:

Relation:

Contact Number:

Family Doctor:

Clinic Name:

Contact Number:

Additional Information

How did you hear about us?:

Do you have Extended Healthcare Benefits?

Type of Service Being Requested:

Brief Description of Concerns:

Method of Payment:

"Pay by third party” means that payment will be made directly by an outside organization or individual rather than the client. Please provide the Third Party’s name and contact information. Note we cannot proceed with services until written confirmation is received via: info@menandhealing.ca, or by fax) from the third party.