Form

First name*

Last name*

Gender*

Pronoun

Phone number*

Email*

Street address*

City*

Province*

Postal code*

College and Registration number(s)*

proof of license/registration*

Bachelor's or Master's Degree*

Liability Insurance*

Please provide a friendly and professional biography (max 90 words) in first person for your profile, promoting yourself and how you help potential clients.
Word Counter if needed.*

Please provide a shortened version of your biography (max 50 words) to be used for some versions of your profile.
Word Counter if needed.*

Please list any other areas you specialize in.

Roughly how many hours a week would you be able to offer as availability to clients?*

Type of Care*

Individual therapy

Couples therapy

Family therapy

Group therapy

Other Types of Care

What, if any, workshops/presentations/webinars are you able to run?

Do you have any professional social accounts, if so what are your social handles?

Please upload a high-quality, professional and approachable headshot (please note that this photo is for potential clients).*

How did you hear about us?*