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Book A Consultation

Effective October 1, 2025

Therapy Intake Form for Ashley Gasewicz Psychotherapy and Consultation Services

Upon beginning your first session, I may ask for you to sign a few more documents (i.e. AI consent form). 

Client Information

Birthday
Month
Day
Year
Multi-line address

Billing Details

Preferred payment method
Credit Card
Cash
Interac e-transfer

Therapy Details

Have you attended therapy before?
Yes
No
Was it helpful?
Yes
No
Unsure

Emergency Contact

Ashley Gasewicz Psychotherapy and Consultation Services
Aria Medical Centre
300 Wellington Street East Unit #2
Aurora, Ontario
L4G 1J5

(289) 926-0565
gasewiczashley@gmail.com

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