Use this form to send us a note. We would love to help!
If the contact form is being completed on behalf of someone else (i.e. child, family member) please use the name and details of the individual who would be coming in for counselling.
Name (required)
Email (required) Phone Number Address
Age Gender femalemaleother
How did you hear about Upstream Counselling?—Please choose an option—GoogleSocial MediaAcquaintanceDoctorOther
What services are you looking for? (check all that apply)
Individual counselling Couple counselling Parenting / Family counselling Clinical supervision
How would you prefer to connect? —Please choose an option—VideoTelephoneIn-personFlexible
How can we help you? (All information shared will be treated as confidential)
Is there a specific therapist you would like to work with?
Are you interested in reduced-fee counselling?YesNo
How do you plan to pay for counselling? Private payBenefits coverage3rd party supportOther
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