Couples+ Counselling

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

Country

(###)

###

####

Partner's/Family/Community Member's/Friend's Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

Country

(###)

###

####

Partner's/Family/Community Member's/Friend's Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Phone

(###)

###

####

We are reaching out for consultation.

15 minutes free phone consultation.

We are in a romantic relationship seeking support with...

Pre-commitment counselling.

Communication styles.

Facilitating our process of creating mutually affirming, healthy boundaries.

Navigating and creating terms to our commitment.

Navigating and creating an accountability process to our commitment.

Questioning/navigating opening or expanding our relationship/s.

Questioning/navigating monogamy.

Exploring ways of intimacy (Inclusive of all genders and sexualities).

Trust in building, restoring, defining our relationship.

Co-parenting with ex-partner/s, new partner/s, friend/s, chosen family, etc.

Ending our romantic relationship/s.

Not listed above, please read my message below.

We are family members/chosen family members/friends seeking support with...

Conflict.

Reconciliation.

Communication styles.

Navigating shared circles/communities.

Navigating and creating an accountability process.

Exploring ways of building/restoring trust.

Exploring ways of building/restoring relational safety.

Facilitating our process of creating mutually affirming, healthy boundaries.

Not listed above, please read my message below.

Privacy and Security *

I understand that communications via email over the internet are not secure. Although unlikely, I understand that there is a possibility that an unintended party could intercept and read the contents of an email. I also give Just Healing Psychotherapy permission to leave a message at the phone number and email address provided.