Receive A $10 Gift Card!

Bonus Opportunity!

Receive $5 for each additional email address (max 3) for mental health referral, for example:
- medical admin office support,
- doctor/specialist, or
- healthcare clinic or other office.

Your Name

Your Email Address

Your Clinic or Business

Your Phone#

(###)

###

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Select Preferred Gift Card

Tim Hortons

Starbucks

Amazon

Recieve $5 Gift Card for Additional Email Address Provided (max 3):

1st EMAIL ADDRESS

1st Name

1st Name of Clinic or Business

2nd EMAIL ADDRESS

2nd Name

2nd Name of Clinic or Business

3rd EMAIL ADDRESS

3rd Name

3rd Name of Clinic or Business