Registration | Session

Relief individual self-management support

Personal information

First name

Last name

Phone number

Format : xxxxxxxxxx

Session

How many sessions would you like to confirm and pay for?

Please select the desired topic for the session

Please choose between virtual and in-person sessions

Session date (optional)

If the date has already been agreed with your mental health worker

Please select the desired topic for the session

Please choose between virtual and in-person sessions

Session date (optional)

If the date has already been agreed with your mental health worker

Please select the desired topic for the session

Please choose between virtual and in-person sessions

Session date (optional)

If the date has already been agreed with your mental health worker

If you have chosen a virtual session, can you confirm that you have a computer, a webcam, a microphone and the Zoom app [free]?

I acknowledge that all virtual meetings take place with cameras on and that I am comfortable with technology.

I understand that the in-person sessions will be held in Montreal at 418 Sherbrooke St. East.

I confirm that I have read the terms and conditions of the service.

By checking this box, I consent to the collection and processing of my personal information in accordance with Quebec's Law 25. I understand that this information will be used solely for the purpose of the provided service and will not be shared with third parties without my explicit consent.

Payment
The amount charged will be $95 per session.

Contact information

First name

Last name

Phone number

Billing information

Address

Address (Row 2)

City

Province

Required field for residents of Canada and the United States

Postal Code

Country

Payment Information

Name on the card

Card number

Please enter the two digits corresponding to the month of your card's expiration date.

Please enter the two digits corresponding to the year of your card's expiration date.

CVV

The CVV/CVC code (Card Verification Value/Code) is located on the back of your credit/debit card on the right side of the white signature strip; it is always the last 3 digits in case of VISA and MasterCard. Please copy your CVV/CVC code from the back of your card and continue with your payment.

Card type

VisaMastercardVisa DebitMastercard Debit

Registration | Session

Relief individual self-management support

Personal information

Session

PaymentThe amount charged will be $95 per session.

Payment
The amount charged will be $95 per session.