Your name *

First Name

Last Name

If couple therapy, name of other person attending

First Name

Last Name

Phone number *

(###)

###

####

Type of therapy *

Individual

Couple

Family

Child/Adolescent

Co-Parenting

In person or video therapy? *

In person therapy only

Video therapy only

Either in person or video therapy

Name *

First Name

Last Name

Name(s) of anyone else attending therapy with you (if applicable)

First Name

Last Name

Phone (if in North America)

(###)

###

####

In person or remote? *

In office

Skype

Phone

Which type of modality? *

Individual Therapy

Couple Therapy

Family Therapy

Child/Adolescent

Co-Parenting after divorce

Other, please specify below

Best times for appointments? (Based on Montreal time) *

Any day

Monday afternoons

Monday evenings

Tuesday mornings

Tuesday afternoons

Thursday mornings

Thursday afternoons

Friday mornings

Friday afternoons

How did you hear about Vikki? *

A friend/relative

Read your blog

Doctor or lawyer referred

Found Online

Other, please specify below: