Client Name *

First Name

Last Name

Parent/Guardian Name (if client is under 18)

*If client is under 18 years old, please enter parent/guardian information here.

First Name

Last Name

Client Date of Birth *

MM

DD

YYYY

Primary Contact Phone Number *

(###)

###

####

What is your preferred contact method? *

Please note that Marie-Claire will initially be contacting you via email - please keep an eye on your inbox for an email from marieclaire@themovingselftherapy.com .

Cell - text only

Cell - text or call - NO voicemails

Cell - text or call - voicemails OK

Email

Have you accessed counselling services before? *

Yes

No

Are you seeking IN-PERSON or ONLINE sessions at this time? *

In-Person

Online

Combination of both

How did you hear about Marie-Claire? *

Personal Referral

Canopy Studios

Psychology Today

Instagram

Facebook

Coeo Healing Collective

Google Search

Autism Calgary

Other