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Yasmin Gaibie Counselling
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Intake form
Help us serve you better
Name
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Email address
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What type of therapy are you interested in?
Please select at least one option.
One-on-one therapy
Couples therapy
Psychedelic integration
What specific issues are you seeking help with?
Please select at least one option.
Trauma
Anxiety
Relationship issues
Self-esteem
Personal growth
Stress management
Have you previously attended therapy?
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Yes
No
What is your preferred method of communication?
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Phone
Email
In-person
How did you hear about yasmin gaibie counselling?
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Referral from a friend
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What are your goals for therapy?
Additional questions or comments
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