Appointment Inquiry Form

Your First and Last Name (For couples please include partner's full name): *

Email Address: *

Date of Birth (MMDDYY) *

Cellphone Number *

May we leave a voicemail message on your cellphone?
YesNo

Home Phone Number *

May we leave a voicemail message on your home phone?
YesNo

Work Phone Number *

May we leave a voicemail message on your work phone?
YesNo

Your Mailing Address

Do you have a preferred pronoun?

How did you hear about Stewart & Associates? Please be specific i.e Google, Yelp, Friend, Doctor, etc.

Which counsellor would you like to book with?

Are you a First Nation Citizen?
YesNo

If yes, What is your status number?

For First Nations: If you or a family member attended an Indian Residential School, please provide the name of the person who attended, their relationship to you, date of birth and the name of the school.

Are you a Nisga'a Citizen?
YesNo

If yes, what is your citizen number?

For First Nations and ICBC clients, please provide your Personal Health Number:

If you are seeking counselling as a result of a car accident, please provide your ICBC Claim Number:

If you are seeking counselling via the Crime Assistance Program (CVAP), please provide your claim number:

Briefly describe why you are seeking counselling.

I have read and agreed to the following cancellation policy at the bottom of this page: *
Yes