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Email counseling
Name
(Required)
Address
(Required)
Phone
(Required)
Email
(Required)
Gender
(Required)
Male
Female
Any Diagnosis of Psychotic illness by a Physician:
(Required)
Yes
No
Message
Choose Package
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20$ CAD for counseling on one primary question
50$ CAD for a package of counseling on 3 primary questions
80$ CAD for a package of counseling on 5 primary questions
Consent
(Required)
I agree
I agree and hereby declare that I am over 21 years of age and that I have never been suicidal in the past and that all the information provided above is true to the best of my knowledge and belief. I further understand that I would be held responsible and liable for any wrong information furnished in this form intentionally or unintentionally. I also understand that I would solely be responsible for any adverse consequences of any of my actions that I decide to take on the basis of my own understanding of the suggestions and advice received through Email counseling.
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