Accelerated Intake QuestionsFull Name *Email Address *Phone *Alternative Phone NumberCityZIP / Postal CodePreferred Form of Contact *PhoneEmailFull name of any other people who will be attending counselling. If any are under 18 years old, please list their age.First and last name of any other people who will be attending counselling.Their age (if under 18)What is your preferred appointment time?MondayMorningAfternoonEveningTuesdayMorningAfternoonEveningWednesdayMorningAfternoonEveningThursdayMorningAfternoonEveningFridayMorningAfternoonEveningSaturdayMorningAfternoonEveningTypeIndividualCoupleFamilyPremarital CounsellingYour gender or identityPreferred SessionsOnlinePhoneIn-personPreferred gender of counsellorYour presenting concernYour gross annual family income and number of dependents so that we can quote a session fee.If you want to utilize a benefit plan, please give us details including the required counsellor credentials.If you are planning on using insurance answer the following few questions:What is your coverage per year?What is your coverage per session?Check off the designations that your insurance covers:1. Registered Clinical Counsellor (RCC)2. Registered Psychologist (R Psych)3. Registered Social Worker (RSW)4. Certified Canadian Counsellor (CCC)5. American Association of Marriage and Family Therapists (AAMFT)6. Registered Marriage and Family Therapist (MFT7. Registered Art Therapist (BCATR)How did you hear about us? Send MessagePlease do not fill in this field.
