GROUP Registration Form

Live well NOW

counselling serviceS INC.

“A designation of BC Association of Clinical Counsellors”

callor emailfor individual, couple, family or therapy group.

Emergency Contact

Birthdate *

If Yes:

Address *

Do you have a professional referral for this group? *

Yes

Name: *

GROUP REGISTRATION FORM

To register in any of the groups offered by LIVE WELL Counselling Service, please fill in the form below.

NOTE: I offer a reduced fee to those referred by the following health care practitioners: medical doctors, RMTs, chiropractor, naturopathic doctors. Other referrals will be considered for discount. Please ask your professional to visit the forms page on this website to fill in the Professional Referral Form.

If you have any questions please feel free to call Teresa - 778-839-4554 or Email me at teresa@livewellnow.ca

Reasons for interest in B.A.S.E. Group *

Emergency Contact

Medical Information *

Email: *

Check here to receive email updates

If Yes:

Emergency Contact

Phone Number *

Is it okay to leave a voice message at this number? *

Yes, this is my private voicemail

Yes, this is a shared voicemail (leave only name and phone number)

Live well NOW​

​counselling serviceS INC.

“A designation of BC Association of Clinical Counsellors”

callor emailfor individual, couple, family or therapy group.

GROUP REGISTRATION FORM

Live well NOW

counselling serviceS INC.