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Review

Please complete the questions on this page on behalf of the person seeking counselling.

Client Information

Tell us a little bit about you, or the person who will be attending counselling. All fields are required unless indicated otherwise.

Your Contact Information

If you are registering on behalf of someone else, please provide your contact information.

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We will ask you for more information on step 3.
Their Contact Information
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Sorry, we are only able to provide counselling within Alberta. Please call 211 to connect with a counselling service in your area.

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Discreet Messages

Our phone number does not show up in caller ID. We can also leave voicemail messages without identifying ourselves for privacy and confidentiality.

Our phone number does not show up in caller ID. We can also leave voicemail messages without identifying ourselves for your privacy and confidentiality.

What if they don’t have a family doctor?
What if I don’t have a family doctor?

If you do not have a family doctor, we can provide information on how to find one at the end of this registration form.

Counselling fees are set on a sliding scale based on your income and ability to pay.
We will ask you for more information about your insurance on page 3.

Previous Counselling

Reasons for Counselling

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We will do our best to accommodate preferences based on our current counselling staff.
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Some individual counselling sessions must be completed to find a good group fit for you.
Please add your partner/family members who may participate in counselling with you on the next page in section People attending counselling

Who referred you?

Family & Household

This information helps us match you with a counsellor that best fits your needs.

Annual household income

Parent's Income

The session fees are based on your household income and ability to pay. Nobody is turned away based on their ability to pay. If you are on AISH or Alberta works, please include that income below. Please give your best estimate.

Please add up the incomes of all adults contributing to your household income.
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Your information

Please complete some additional information for the person who is completing this form and will either be participating in counselling, or is the parent/guardian of a child who will participate in counselling.

Complete your information
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Additional people attending counselling

Please list additional people who may participate in counselling below

Please list people who may participate in counselling below.

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Add another person

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Add a person

Edit a person

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Discreet Messages

Our phone number does not show up in caller ID. We can also leave voicemail messages without identifying ourselves for privacy and confidentiality.

Our phone number does not show up in caller ID. We can also leave voicemail messages without identifying ourselves for your privacy and confidentiality.

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You can remove them from your list of people attending counselling, or you can edit their record.

Insurance & Fees

In order to assign you to a counsellor with the qualifications required by your insurance provider, we need the following important information:

Please note Calgary Counselling Centre is only able directly bill Alberta Blue Cross and Medavie Blue Cross. For other insurers, we provide a receipt that you can submit to your insurance provider for reimbursement. Please check back on our website for other providers.

Please note Calgary Counselling Centre is not able to directly bill secondary insurance plans. We provide a receipt that you can submit to your secondary insurance provider for reimbursement.

Counselling fees

Based on your income, your estimated session fee is ${{this.steps[4].feeQuoted.val}}

This fee has been calculated on a sliding fee scale based on your household income.

If you cannot manage the quoted fee, please tick the box below and a counsellor would be happy to discuss it with you. Nobody is turned away based on their ability to pay.

We are funded by fees scaled to the income of clients, generous funders and donors, occasional government grants, and partnerships which support specific projects. Calgary Counselling Centre does not receive government funding for our day-to-day operations.

Counselling Questionnaire

The following questions are asked to everyone, and may or may not apply to you.

Are you or any family member coming for counselling currently in treatment for any medical problem, including taking medication of any type?

Prescription medications can sometimes affect one’s mental health. This can be important for your counsellor to know about. Brand names are not necessary.
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Is there a concern about the use of any of the following?
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The Distress Centre can be reached at 403.266.4357

If you need to speak with someone right away and it is after-hours or on a weekend, please contact the Distress Centre at 403.266.4357

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Final Information

We use this optional information to evaluate and improve our programs, and to improve the services we provide you. We appreciate you taking the time to complete this section.

Including yourself, how many people live in your household?

Review & Submit

Please review the information you provided, then complete your registration by submitting the form.

Your Contact Information  
Edit
Registering on behalf of a child under 18
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Your first name
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Your last name
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Your Email Address
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Email opt-in
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Your relationship to the client
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Will be participating in counselling
{{steps[1].behalfParticipatingInCounselling.val ? 'Yes' : 'No'}}
Parent/legal guardian of a child under 18 who will participate in counselling
{{steps[1].behalfGuardianParticipatingInCounselling.val ? 'Yes' : 'No'}}
Client Information  
Edit
First Name
{{steps[1].firstName.val}}
Last Name
{{steps[1].lastName.val}}
Gender
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Date of Birth
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Email Address
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Email opt-in
{{steps[1].emailOptIn.val ? 'Yes' : 'No'}}
Occupation
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Contact preference
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Address
{{ steps[1].address.val + ', ' + steps[1].city.val + ', ' + (provinceOptions.filter(x => x.Value ==steps[1].province.val)[0].Name) + ' ' + steps[1].postalCode.val }}
Previous counselling?
{{steps[1].hasHadCounselling.val ? 'Yes, I have previously received counselling' : 'No'}}
Emergency Contact Name
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Emergency Phone Number
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Family doctor
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Treaty Status
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Band Name
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Treaty Number
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Veteran Status
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Reasons for Counselling  
Edit
What is bringing you in?
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Counsellor preferences
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How long has this been a problem?
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Has this situation been getting worse?
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Interested in counselling for

Myself

My partner and I

My family

My Child/Children

Group

My preference for counselling is:

In Person

Online

My availability for counselling is:

Anytime

Days

Evenings

Saturdays

Referred by
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Family & Household  
Edit
Marital status
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Employment status
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Household income
${{houseHoldIncome}}
Additional people attending counselling

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Insurance & Fees  
Edit
Do you have insurance?
Yes, {{insuranceSourceOptions.filter(c => c.Value == steps[4].insuranceSource.val)[0].Name}} No
Based on your income, your estimated session fee is
${{steps[4].feeQuoted.val + (steps[4].discussLowerFee.val ? ', need to discuss a lower fee option' : '')}}
Counselling Questionnaire  
Edit
Is English your first language?
{{steps[5].englishFirstLang.val == 'yes' ? 'Yes' : 'No'}}
What languages do you speak at home?
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Is anyone coming for counselling taking medication?

{{steps[5].currentMedicalTreatment.val == 'yes' ? 'Yes' : 'No'}}

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Concerns about alcohol, drugs, or gambling?

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Concern about violence?

{{steps[5].violenceConcern.val == 'yes' ? 'Yes' : 'No'}}

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Concern about suicide?

{{steps[5].suicideConcern.val == 'yes' ? 'Yes' : 'No'}}

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Is there any additional information you would like to give us?

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Final Information  
Edit
How did you find out about us?
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People living in your household
{{steps[6].houseHoldAdults.val + ' adult' + (steps[6].houseHoldAdults.val > 1 ? 's' : '')}} {{steps[6].houseHoldChildren.val > 0 ? (', ' + (steps[6].houseHoldChildren.val + ' child') + (steps[6].houseHoldChildren.val > 1 ? 'ren' : '')) : ''}}
Why did you choose us?

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Are you paying more than 25% of your take home pay for rent or mortgage payments?
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Ethnic background

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Highest level of education
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Were you born in Canada?
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Visible minority?
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Would you consider yourself
Able Bodied Person with Mental Disability Person with Physical Disability Person with both a Mental and Physical Disability
How many years have you been living in Canada?
Less than a year Over 10 years {{steps[6].yearsInCanada.val}}

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