YEG Family Counselling Intake Form
We do intakes in two ways. You are totally welcome to book an inquiry / intake appointment HERE but if you are pretty sure you just want to book in with one of our therapists OR you are a millennial that hates the phone, please feel free to fill out this form instead.

First things first ~ the FINE PRINT.

1. Benefits and risks: While this form doesn't go into depth about what you are struggling with, it can still be painful to share these things. It's always the hope that even the effort to connect will be a helpful process, and we will do our best to make sure this information informs our next steps.

2. Limits to confidentiality: This information goes directly into our Google Workspace and is viewed by internal staff only. The information you share here will be used to assign you the right therapist and get you the help that you need. Other limits to confidentiality that we always have to follow include if you are at risk of immanently harming yourself or another person, if there is a child or other vulnerable person being harmed, if there is a work-related injury, or if your file is subpoenaed. Your information will be collected, stored, and used according to PHIPA. 

3. Other details: This is the only way we have of getting to know you, but we also want to be respectful of the amount of information you have to put on paper. With that being said, you can share as much or as little as you think we should know. It's our practice to always make sure you have the right set of supports, so if there is no one in our clinic that would be a good fit, we will always try to find several other names for you and help you make connections as needed.
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Email *
What is your name? (the person filling out this form) *
What are your pronouns? *
What is the best phone number for booking? *
Can we leave a message if you do not pick up? *
How did you hear about us? *
Required
If you were referred by another therapist, pleast list them here - it gives us good info! *
What type of therapy are you inquiring about? *
Required
What is your desired format for therapy? We provide online, in-person, and mixed format therapy. *
Who will be coming to therapy? (If you're the only person, say, "just me!) *
Please list the first names and a short description of everyone who will be attending (ex., Joan -self/parent, Jane partner / stepmom,  Sally - 12, Johnny - 9; Molly - bio mom). You can include pronouns if helpful.
Are you applying for the Affordable Counselling Program? *
The Affordable Counselling Program is for folks who have limited income and/or no insurance. This program is made possible by our Mental Health Therapy Interns who are in the final stages of completing their Masters Degree. They are highly supervised by Amy Nydam, R.Psych. Find out more about this program here.

*Please note that at this time, the program is only available for clients ages 10 and up. 
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