Name
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First Name
Last Name
Email
*
Phone
*
(###)
###
####
Preferred Contact Method
*
Type of Session
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Our counsellors work at specific locations, but all are available for online sessions regardless of location. If your preferred counsellor doesn't work at your preferred location but you are open to online sessions, please indicate so by selecting "Either".
Office Location
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Select all that may apply.
Demographic
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The requested counselling is for a:
Reason for Counselling
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Please briefly describe your top 1-5 reasons for seeking counselling, in order of priority. Not all counsellors work with all issues and our best-match approach is aimed at pairing you with the counsellor best suited to help while prioritizing what is most important for you to address first.
If the client is a child or youth, please provide their full name, date of birth, and the contact information of any other legal guardian or parent for consent purposes. Note: We do not work with high-conflict or court-involved family separation or divorce cases involving minors. We can refer you to a more suitable office if needed.
Child's Full Name - Age - Date of Birth
Legal Guardian/Other Parent Full Name - Phone Number - Email Address
If requesting Couples/Family counselling, we need to get in touch with all participants prior to booking. Please indicate the full names, emails, and ages of each person who will be participating in the sessions.
Person 1 - Name - Age - Email Address
Person 2 - Name - Age - Email Address
Counsellor Preference
If known, please indicate the names of your top 3 choices of the counsellor that you would like to see. Based upon your reason for seeking counselling, our intake coordinator will suggest a counsellor for you who will best be able to help you. We do our best to pair everyone with their counsellor of choice, however, this may vary due to individual counsellor availability, days/times of the week, the reason you're seeking counselling, and the approaches that each counsellor uses. Based on what you indicate and our expertise, we may make a recommendation for who we feel would most closely be able to fulfil what you are looking for.
Preferred Appointment Times
*
Individual counsellor availability varies. There may be a wait for evening/weekend appointments due to high demand. If you are able to do a daytime appointment, please indicate so below in order to be able to get started with a counsellor sooner. Please include as many options as possible below for when you are generally available week-to-week.
Affiliation or Claim Information
*
If relevant, please indicate which of the following fields apply. Please note, most extended health plans will cover counselling with an RCC, CCC, or RSW - please verify your coverage with your plan provider. We are able to direct bill to select extended health plans that allow counsellors to. Where we aren't able to direct bill, you will be issued a detailed receipt which you can submit to your plan directly for quick reimbursement.
Anything Else You'd Like Us To Know?
How Did You Find Us?
*
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