Thank you for reaching out.

Thank you for your interest in working together.
This form helps me understand a little bit about what you’re looking for so I can respond with care and clarity. Please only share what you feel comfortable sharing. This form is not monitored 24/7 and is not for emergencies.

Please enable JavaScript in your browser to complete this form.

Name *

First

Last

Email *

Phone

Preferred Contact Method

• Email
• Phone

Are you currently living in Ontario?

• Yes
• No

How would you like to meet?

• In-person in Burlington
• Virtual (within Ontario)
• I’m open to either

Have you worked with a therapist before?

• Yes
• No
• Prefer not to say

Areas you’re seeking support with

• Anxiety
• Postpartum depression or adjustment
• Life transitions (parenting shifts, divorce, career changes, grief, etc.)
• Identity, relational or emotional shifts that can arise during perimenopause and menopause
• Stress / overwhelm / burnout
• Work-life balance
• General emotional well-being
• Other (please specify)
• Prefer not to say

General availability for sessions

Eg. Daytime, Evenings…

How did you hear about Moscato Counselling & Psychotherapy?

• Google search
• Instagram
• Referral from a friend or family member
• Referral from a healthcare provider
• Other (please specify)

hear Contact Name

Checkbox (required) *

• ☐ I understand that this form is for non-urgent inquiries only and that I will receive a response as soon as reasonably possible.

Submit

This form is not monitored 24/7 and is not suitable for urgent or crisis situations.
If you are in immediate distress or concerned for your safety, please contact your local crisis line, go to the nearest emergency department, or call 911.