Appointment Request Form

To schedule an individual, children, couples, marriage or family therapy appointment or to obtain additional information about any of these therapeutic services, please fill out the form below :

Client Name

Email Address

Contact Tel #

Type of Counselling you are interested in:

Individual

Young Adult

Couples

Family

Specific Condition

Check one or more

Additional information you wish to share at this time

All information submitted will be confidential

Date of Appointment Request

We will contact you to verify and confirm this request.

Time of Appointment Request

We will contact you to verify and confirm this request.

How did you hear about us?

This question is simply to find out how people are hearing about Wellness Family Therapy - Thank you!