Our Services

Intake Form

Your preferred phone number is required so that our Clinical Director can speak with you to complete the intake process. To protect your privacy, please do not include any personal health details in your message.

You only need to share enough for us to understand how we can support you. You don’t need to describe traumatic experiences in detail at this stage.

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Full name *

First

Last

Email *

Phone number *

(OW) us? or

May we leave a voicemail at this number? *

• Yes
• No

Full Address (Number, Street, City, Postal Code)

We provide services to our local community in the Region of Waterloo. Please call our offices if you reside outside of the region and want to receive our services.

Date of Birth

Additional Person(s) Information (Required for Couples/Family Counselling)

Please include additional person(s)’s name, address, date of birth, and length of relationship (if applicable).

Emergency Contact

Please provide the name, relationship, and phone number of someone we could contact in an emergency.

What brings you to counselling right now? *

Reason for Seeking Counselling. Share as much or as little as you’re comfortable sharing.

Have you received counselling before?

If yes, where and when?

Gender identity (optional)

We ask this to help provide respectful and affirming care.

Pronouns (optional)

We ask this so we can address you respectfully.

Cultural, ethnic, or racial identities (optional)

You may share any cultural, ethnic, racial, or community identities that are important to you.

Is there anything else you would like to share with us?

Do you currently receive Ontario Works (OW) or the Ontario Disability Support Program (ODSP)? (Optional)

• Ontario Works (OW)
• Ontario Disability Support Program (ODSP)
• No

This information may help us determine whether you qualify for funded counselling.

Family doctor (optional)

If you have one, what is the name of your family doctor? Some physicians participate in programs that may help fund counselling.

Do you have insurance coverage for counselling?

• Yes
• No
• I’m not sure

Submit