MAIL-IN ORDER FORM FOR ONLINE COUNSELING ( )

							                    MAIL-IN ORDER FORM FOR ONLINE COUNSELING

       DIRECTIONS: PLEASE PRINT, COMPLETE THE THREE SECTIONS BELOW AND MAIL TO:

                                          GAY MEN’S COUNSELING
                                        224 Garden Drive North, Suite 205
                                            Vancouver BC V5L 3E7
                                                   CANADA

SECTION ONE:

______________________________________________________________________________________
First name                                 Last name

______________________________________________________________________________________
Street address

______________________________________________________________________________________
City                                       State/Province              Zip/Postal code

( )
______________________________________________________________________________________
Home telephone number                                Email address

The personal information collected here will only be used by GAY MEN’S COUNSELING to process this order.
This information is never shared with third parties.

SECTION TWO:

Please choose from one of the four online counseling options below:

                     One 60-minute counseling session via secure text-messaging chat room.
           Option A: Fee: $100 US.


                        One 60-minute counseling session via telephone.
           Option B:
                        Fee: $100 US (long distance charges are the responsibility of customer).

                     Two email exchanges with our Registered Clinical Counselor.
           Option C: Fee: $175 US.


                        One email exchange with our Registered Clinical Counselor.
           Option D:
                        Fee: $100 US.


SECTION THREE:

•   Total amount enclosed: $_________________

•   Please pay by International Postal Money Order in US funds to the order of:
    James Joly, M.Ed., RCC.

•   International Postal Money Orders are available at your local post office. We regret that personal checks cannot
    be accepted for payment and will be returned. Thank you for your patronage!