Intake Form for Couples Counselling
Please note, our new fee is $130 per session to see a Clinical Counsellor (RCC or CCC).
Use this form if you have a combined gross income of $50,000  or more.

 

Personal Information, Client 1 (Main Contact)

arrow&v
arrow&v
arrow&v
arrow&v

Contact Information for Client 1 (Main Contact) 

arrow&v
arrow&v

General Information

What format of counselling would you prefer (check all that apply)
Choose the days and times that you are available for counselling. Please choose carefully as these times/days will be used to set up your future appointments. Please note, counsellor availability is limited on Saturdays and Sundays.
Presenting concerns, click all that apply:

Financial and Payment Information 

Please note, as of March 1, 2022 our counselling rate is $130 per session to see one of our Clinical Counsellors.
For any online counselling (video or phone) a credit card, visa/MC debit, will be required for payments. Your payment method must be set up in the Jane App system either before or during your first appointment. All payments will then be processed at the end of each counselling session by your counsellor. We do not accept e-transfers. 
For in-person sessions we accept credit card, debit card or cheque. 

Extended Health Coverage (please check appropriate box). Please note we are not set-up for direct billing to insurance agencies.

Counsellors

Other

arrow&v
arrow&v
arrow&v

Personal Information, Client 2 (Partner)