JaneApp-newclient

New Client Profile for Virtual Therapy

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Client First Name

Client Last name

Preferred Name

Pronouns

Phone number

Street Address

City

Province

Postal Code

Birth Date

Gender

Family Doctor

Family Doctor Phone Number

Parent/Guardian

Parent/Guardian Phone Number

If under age 16, is legal guardian aware of your request for counselling?

Yes

Occupation (if applicable)

Cardholder Name for Billing

Credit Card Number

Credit Card Type

Visa

Mastercard

American Express

Expiry Date (MM/YY)

I hereby authorize A Well Mind to charge my credit card in the amount of $160 per booked therapy session.

Yes

How did you hear about A Well Mind?

A Well Mind

182 Wellington St.

Third Floor

Bowmanville, Ontario L1C 1W3

Telephone: 289-312-MIND (6463)

Email: [email protected]

Questions?

289-312-MIND(6463)

16 Silver Street, Bowmanville Ontario L1C 3C3

Please note, we are not a crisis centre. If this is a psychiatric crisis, mental health, or medical emergency, please go to your local emergency department, call 9-1-1, or a local distress line.

ConnexOntario: 1-866-531-2600

Durham Mental Health Services: 1-800-742-1890

Ontario Shores Crisis Line: 1-800-263-2679

Kids Help Phone: 1-800-668-6868

Distress Centre Durham: 1-800-452-0688

Psychological Testing & Mental Health Services

New Client Profile for Virtual Therapy

Contact Us

A Well Mind