Your Name: 

e-mail address: 

Your sex:     Male        Female

Your Partner's name:

Partner's Sex:    Male        Female

Tell us what you'd like to work on:

Tell us about the duration of this issue:

How have you dealt with similar issues in the past?

Tell us a bit about yourself (age, family of origin, relationship(s) you're presently in, medical conditions you've had or are prone to, where you carry stress in your body, etc.)

Then, provide the same information about your partner.

We will be contacting you be e-mail. Are you comfortable that your e-mail is sufficiently private? If you click "yes" we will respond to the above e-mail address with our assessment. If "no," please use the following box to suggest an alternative way (i.e. FAX to communicate with you.)

Yes            No

Alternate arrangement suggestion (optional field)

Please share what you have in mind re. counselling, i.e.
that you'd like to set up regular, paid telephone counselling, or
that you'd just like some feedback, or
you'd like more information about coming here for direct work with us, etc.