Dr. Gloria Lee

Thank you for your interest in working together. This application helps me understand your situation and determine if we're a good fit. Please answer thoughtfully — your responses give me valuable insight into your patterns and what we'll work on together. All information you share is strictly confidential and will only be used to assess fit.

First Name

Last Name

Today's Date

Phone Number

Partner's First Name (if applicable)

Partner's Email (if applicable)

Partner's Phone Number (if applicable)

Location & Time Zone

Are you applying for counselling or coaching?Counselling (BC residents only)Coaching (I live in Canada, outside BC)Coaching (I live outside Canada)

How did you hear about me?

Provide a brief description of your relationship challenges

On a scale of 1–10, how would you rate your relationship satisfaction right now?

What have you already tried to fix this?

If you've worked with other therapists or coaches before, what worked and what didn't?

Why are you seeking support now? (What's changed? What's the urgency?)

Can you commit to attending sessions consistently for 3 months (may be extended if needed)?

Are you aware of the investment? (approx. $7,200 for 3 months — twice a month, 2 hours per session)

I work online (Zoom) on Tuesdays and in person in Burnaby on Wednesdays, 12 to 4 PM PT. Would one of these work for you?

Is there anything else you'd like me to know about your relationship or situation?

Next steps: I review every submission personally and will respond within 3–5 business days.