Counselling Intake Form

Name *
Please include your preferred name and your full legal name.
Phone *
Address *
Name, Relationship to you & Phone Number
Do you have a history of any of the following? *
Addiction History
If you selected yes to having a history of addiction, please specify:
Please indicate if this has happened in the past and/or if this is something that you are currently experiencing.
Do you think you have enough support in your life right now? *
Do you think you have enough support in your life right now?
Please indicate on the scale how much support you currently have. Eg: Strongly disagree=no support, Strong Agree = enough support
Who do you have for support? *
Confidentiality *
Your confidentiality is taken very seriously and will be respected. No information will be released about you except for in the following circumstances: * If you give consent * If your safety or someone else's safety is in question * If there is reason to believe that a child/minor is at risk of being harmed * If your file is subpoenaed and required by law


Payment is required in advance to secure your booking in groups, workshops & individual sessions. Payment can be made via e-transfer to

Please note that a minimum of 48 hours notice is needed to cancel or reschedule any sessions; if this notice is not given, full payment is still required and will not be refunded. (Exceptions can be made in extenuating circumstances).

Individual/Couples Therapy Session - 1 Hour: $115.00

Individual/Couples Therapy Session - 1.5 Hours: $170

Groups & Workshops - Please see price indicated for each individual workshop advertized as prices may vary.