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We are committed to protecting your privacy and ensuring the
confidentiality of your personal information.

The information collected through this form is used solely for the purpose of providing you with our counselling and therapy services. This may include contacting you to schedule appointments, sending important updates or reminders, and tailoring our services to meet your specific needs.

Name

First Name

Last Name

Reason for seeking therapy

Phone

Type of Service:

Do you have a preferred therapist?

Preferred Location:

Any further information:

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email:

hello@heartandmindpsychology.org

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