COUPLES Counselling - Intake Form

Name *
Name
Please include your preferred name and your full legal name.
Partner's Name
Partner's Name
Please include preferred name and your full legal name.
Phone *
Phone
Address
Address
Name, Relationship to you & Phone Number
Please indicate which of the following apply to you: *
Would you describe your relationship with your partner as "healthy'? *
Would you describe your relationship with your partner as "healthy'?
Healthy = able to communicate well and work through problems together
Please specify who has a current or past experience with: Emotional Issues, Relationship Issues, Codependency, Anxiety, Depression, Other Mental Health Issues, PPA/D, Body Image Issues, Eating Disorder, Addiction
If you selected yes to either of you having a history of addiction, please specify: Alcohol, Recreational drugs, Prescription Drugs, Gambling, Food, Sex, TV, Phone, Gaming, Shopping, Other
Types of abuse: Physical, Sexual, Emotional, Psychological, Intellectual, Financial
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? *
Would you describe your relationships with your family of origin (your parents & siblings) as healthy? *
Would you describe your relationships with your family of origin (your parents & siblings) as healthy?
Healthy = able to communicate well and work through problems together
Would you describe your friendships and other relationships outside of your family as healthy? *
Would you describe your friendships and other relationships outside of your family as healthy?
Healthy = Close, supportive, open communication
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

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

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: $95.00

Individual/Couples Therapy Session - 1.5 Hours: $135

Group Session - 2 Hours: $60

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