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Accepting Clients

CONTACT

Address: 125 Dundas Street W, Thamesford, Ontario

Email: info@commyounitycounselling.ca

Tel: 519-285-2525

Person completing this form

Client First Name

Client Last Name

Date of Birth

Phone

Session availability

Do you have benefits to cover MSW/RSW?

Yes

No

How many sessions are you hoping for?

Preferred Therapist

With whom does the client live with

Email

Please describe the reasons for seeking counselling

Any additional information:

CommYOUnity Counselling and Family Support Ltd. info@commyounitycounselling.ca 519-285-2525 125 Dundas Street, PO box 298, Thamesford, Ontario

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