Client Registration – Integrated Health Transformation Centre

Client Registration

Name *

First

Last

Email *

Cell or phone number *

(999) 999-999

Gender *

Marital status *

Significant other

First

Last

Optional if you wish to enter a partner’s name or any person nearest to you.

Describe your need *

Briefly describe your need if you feel free to do so. Your information is kept confidential. Write “Rather not say” if you need to.

Consent *

By checking this you give consent for an initial virtual assessment

I hereby consent to a virtual assessment by IHTC personnel by either credentialled or non-credentialed staff. The purpose is to decide on entering an ongoing therapeutic relationship. We will normally reach out to respond to your request with an email from healing@ihtc.info Watch you junk mail folder as it is unlikely this email is in your list of contacts.

We will keep your personal information in strict confidence and we will not share or sell your email address with any other organization.