Calgary Counselling Centre - Intake Form

Welcome to our Online Intake System

Please fill in all the fields that apply to you. This will take about 10-15 minutes of your time. Your personal information will be kept secure and will not be used outside of Calgary Counselling Centre. If you would rather fill out the form manually, you can download an Intake Form and fax it to (403) 265-8886. You may also call our office at (833) 827-4229 to complete an intake by phone. Upon receipt of your form, a counsellor will contact you within two business days.
Please answer all the questions in this section as your answers will determine which forms you will complete
Are you married, or have a partner you live with?	Yes No
Do you have other live-in family members (including children)?	Yes No
Do you or your partner have insurance to cover counselling?	Yes No
Have you received counselling in the past?	Yes No