Personal Information
Contact Information
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 Information (proof of income is required in order to qualify, Gross Annual income must be under $25,000 and you have no access to benefits or insurance). Please choose your employment status: Gross annual income is shown on line 150 of your tax return. South Island Counselling reserves the right to request formal documentation for proof of income. Examples of proof of income are tax returns, pay stubs, disability insurance, letter from employer, pension documents, or unemployment documents. The applicants subsidy form will not be processed until proof of income is sent to info@southislandcounselling.org If the applicant is under the age of 18, parent(s) proof of income will be required. For couples and family counselling please use the $60 intake forms as this is our minimum fee for this type of counselling.
Subsidy is granted only when funding is available. The subsidized rate is valid for up to 12 sessions. All subsidy applications are subject to approval by South Island Counselling Management. Due to the limited availability of subsidies, please also explore other funding sources. Please include additional notes and documents if there are other extraordinary circumstances that affect your ability to pay. All information will be kept strictly confidential.
Methods of Payment For any online counselling (video or phone ) a credit card, visa/MC debit, before 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 session, we also accept cash and cheque. I understand I will need to a credit card or visa/mc debit in order to qualify for online counselling. If I have neither of these then I will only be able to access in-person sessions from my counsellor.
Other Have you had any previous counselling at South Island Counselling? Previous counselling at SICCT? How did you find out about us Submit form
