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ISNA Counselling and Therapy Intake Form
Please enter your information below to be registered for a counselling session with a member from our counselling team.
counselling@isnacanada.com
647 370 7616
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* Indicates required question
First Name
*
Your answer
Last Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Email
*
Your answer
Phone Number
*
Your answer
Address
*
Your answer
Are you seeking
*
Islamic Support
Mental Health Support
Briefly detail what sort of help you may require (If you are filling this out for someone else, please indicate that)
*
Your answer
Have you been for counselling before?
*
Yes
No
Counselling Preference
*
In-Person at ISNA
Online
Payment
*
I have private health insurance, please charge me.
I am able to make a full payment for my session. $150/Hour or $80/30 Minutes
I would like to make a partial payment. (Sliding Scale from $15 to $150, what I can afford)
I need ISNA Canada to fully subsidize my session.
Profession?
*
Your answer
Employer
Your answer
How did you hear about our counselling service.
*
ISNA Masjid
Friend/Family
Social Media/Online
Googled It
Referred
If you were referred, please provide the full name of individual/clinic/imam?
Your answer
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