top of page

Intake Form for Family Counselling - $130
Use this form if you have a household gross income of $50,000 or more and /or
you would like to be set-up with a Registered Clinical Counsellor.

Personal Information, Client 1 (Main Contact)

Contact Information for Client 1 (Main Contact) 

Is ok to leave a message at this number?

General Information

What format of counselling would you prefer (check all that apply)
Choose the days and times that you are available for counselling. For in-person sessions, we suggest booking 6-12 appointments ahead with your counsellor, though its optional. Consistency in your appointment day and time is recommned due to limited room availability. You can modify appointments with 48 hour' notice if space is available, otherwise, a virtual session may be necessary.
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.



Our Disclaimer:

South Island Counselling is a non-profit organization attempting to alleviate the immense need for affordable mental health services. We will not tolerate any harassment, hostility, or any form of aggression or abuse towards any of the counsellors or staff at any time. If we feel a client or potential client has committed any of the above, we will not provide counselling services.

Family Information, Partner or other member of family seeking family counselling:

bottom of page