Name *

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

What kind of service are you looking for? Check all that apply:

*if you apply for 2 or more groups you will receive a 20% discount

Men with ADHD Mini Group

Assessment Services ($220/hr)

Counselling Services -adult, family, child, teen, couple etc. ($175/hr)

Payment options (Check all that apply):

I qualify for funding (please see below)

I have extended benefits - pay up front and reimbursed (we will email or call for a credit card authorization)

I don't have funding or benefits but can pay the full rate (we will email or call for a credit card authorization)