Request Mental Health Therapy Services or Coaching

Service Request Form

Request services with Shaylynn Hayes-Raymond virtually.

Email(Required)

This email will be used for booking, communication, and reminders.

Phone(Required)

Client or Legal Guardian Phone Number

Would you like a free 30 minute consultation, or a full 1 hour appointment (full price, less wait time).

Please note that there is limited availability for free consults per month.

Client Location(Required)

State / Province / Region Country

This is necessary for legal reasons.

Client Name(Required)

First Last

Client Date of Birth(Required)

Please select reasons for requesting services.(Required)

Please note, if you are in the USA, the only service available is coaching for misophonia. All counselling topics are available in Canada.

Do you have any questions, comments, concerns, or relevant info?

ALTCHA