Pay in Kindness Program
944 King St. W, Kitchener, ON
payinkindness@exhaletherapy.ca                                                                                                                                                             Primary: (226) 647-1710
Secondary: (226) 338-4158
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Email *
Name *
Email Address *
Phone Number *
Relationship Status *
Are you currently employed? *
Do you have a benefits plan through work, school, or a family member? *
If you answered yes, does the benefits plan include any counselling coverage?
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Have you attended counselling in the past? *
If yes, when and for how long?
Aside from cost, are there any factors that have deterred you from seeking counselling in the past? *
What type of counselling are you looking for? *
What are some of your goals for counselling? *
What do you consider to be some of your greatest strengths? *
What do you consider to be some of your greatest challenges? *
Have you dealt with any significant life changes or stressors in the last few years? If so, please share your experience with us.
Is there anything that might impede on your ability to fully engage in the therapeutic process? If so, please elaborate.
Taking into account such habits as diet, sleep, and exercise, how would you rate your overall physical health at this time? *
Taking into account such things as stress, mood, and ability to cope, how would you rate your overall mental health at this time? *
In the section below, please identify if there is a family history of any of the following:
Do you currently struggle with any of the above? If so, please elaborate.
Are you currently taking any prescription medication? If so, please elaborate.
Tell us about an act of kindness that you performed or witnessed at some point in your life.
One of our goals for the Pay in Kindness program is to connect with community members and remind them that they are not alone on their journey towards mental wellness. If given a spot in this program, would you be comfortable providing anonymous feedback regarding your experience? *
Essay Question: This is your opportunity to tell us a little bit more about who you are and why you have chosen to reach out for support at this point in your journey. What are you passionate about? Who do you look up to? What are some of your plans for the future? What are your biggest worries, hopes, and dreams? There is no right answer to this question; this is your story and your truth. *
A copy of your responses will be emailed to the address you provided.
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