Inner Light Psychology - Psychological Services - Therapy and Assessment

New Clients

Please complete this form (or call my office: 226-341-7456).

Please note email (including this form, which is sent to me from this site via email) is not a secure method of communicating. You are welcome to call my office number to leave a confidential voicemail with your contact information and reasons for reaching out if you prefer.

Name

First Name

Last Name

Message

Please briefly describe your primary concern(s)

Inquiring about

Therapy

Psychodiagnostic Assessment

Who will be the client?

Myself

My Child

Acknowledgment

Please indicate you have read and agree:

Services can only be provided to individuals in the province of Ontario

Phone

(###)

###

####

Post Mail:

P.O. Box 6151
30 Huron St.
New Hamburg, ON
N3A 1A0

Dr. Agar at Inner Light Psychology