New Client Interest FormThank you for your interest in accessing the services at Panorama Wellness Group. Please take a moment to complete our New Client Interest Form so that we can help you find the best therapist for you and your needs. Panorama Wellness New Client Inquiry Form First Name Last Name Gender -None- Female Male Non-binary Pronouns -None- she/her he/him they/them Age Group -None- Younger than 10 10-13 14-17 18-25 26-39 40+ 60+ Phone Email Services What are you looking for help with? What type of appointments would you prefer? -None- In-person Online I have no preference Client Availability Location If you are looking for counselling, please let us know who it is for Are you looking to connect with a specific person? How will you be paying for your appointments? We cannot direct bill to extended benefits but we can provide you with a receipt for submission. Reduced Rate Services -None- I am able to access full-rate services I am in need of reduced rate services and open to working with a Masters-level student. How did you hear about us? -None- Google Search Instagram Facebook A family member or friend Facebook group referral Another professional My clinician at Panorama Wellness Group recommended another clinician on your team Professional directory search I am a returning client WhatsApp - Panorama Wellness Group I consent to PWG using my number to contact me about their therapissts and scheduling a session. Powered by Bigin
