Individual & Group Counselling Registration Form

Name:

Age:

Name of Parent/Guardian:

(if client is a minor)

Sex:
MaleFemale

E-mail:

Phone:

HomeAddress:

Type of Counseling: (tick appropriate box)

Session availability (best day for you): (visit www.axiomcounsel.com and book your appointment now)

MondayTuesdayWednesdayThursday

Preferred time of the day: (visit www.axiomcounsel.com and book your appointment now)

Early morningLate morningEarly afternoonLate afternoon

How did you find out about the Axiom Counselling?

Other therapistInternetFriend/Family MemberOther

Payment & Other Information:

Payment:
ChequeCashDirect DepositOnline Bank Transfer

Please make deposit into:

Scotiabank Account# 001211205: Axiom Counselling (Tunapuna Branch).

Please note the following:

All information detailed in registration form will be kept confidential.
Client on registering and booking an appointment will be asked to complete an intake form and also sign a cancellation policy.