Subsidy Intake

Personal Information

First Name

Preferred Name

Last Name

Age (client must be 16 or over)

Gender

If you selected other, please specify

Preferred Pronoun

Address

Choose city/municipality

Other municipality:

Postal Code

Province

Contact Information

Phone

General Information

What format of counselling would you prefer (check all that apply)

In-person

Video call

Phone

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.

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Mornings (9am-12pm)

Afternoons (12pm-4pm)

Evenings (5pm- 8pm)

Anytime Saturday

Anytime Sunday

Presenting concerns, click all that apply:

Alcohol/Drug Use

Anger Management

Anxiety/Stress

Depression

Eating Concerns/Self-Esteem/Body Image

Family Challenges

Grief and Loss

Gender Identity

Intimacy Issues

Life Transitions

Mood Changes

Sexual Identity Concerns

Spiritual Development

Trauma

Briefly elaborate on your presenting concerns:

Financial Information (proof of income is required in the form of a tax assessment. The counselling rate will be calculated by multiplying Gross Annual Household Income by 0.1%) and our minimum fee is $25/session. In order to qualify, Gross Annual Household income must be under $50,000 and there is no access to benefits or insurance.

Gross Annual Household Income

Fee Calculator

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Please choose your employment status:

Gross annual income is shown on line 150 of your tax return. Household income includes every member of your family over the age of 25 living together. 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 regular intake form or Couples and Family Form.

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, will be required for payments. Your payment method must be set up in the Jane App system 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?

If you chose yes, please enter your previous counsellor's name:

How did you find out about us

Please, specify

I hereby confirm that the information provided herein is accurate, correct and complete. I understand that by submitting the subsidy application I will be paying a subsidy fee of less than $50 per counselling session and is based on 0.1% of my gross annual income. I understand that in order to complete the subsidy application, I must send proof of income to info@southislancounselling.org