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Step {{currentStep}} of 6


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.


Counselling Alberta uses electronic communication, such as email, to set up appointments and provide information and tools related to counselling. Email is the most efficient way for counsellors to communicate with you, if needed.

We require your consent to communicate with you via email.

We will ask you for more information on step 3.
Their Contact Information

Sorry, we are only able to provide counselling within Alberta. Please call 211 to connect with a counselling service in your area.

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.

Counselling fees are set on a sliding scale based on your income and ability to pay.

Previous Counselling

Reasons for Counselling

We will do our best to accommodate preferences based on our current counselling staff.
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.

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
{{steps[3].behalf.firstName.val + ' ' + steps[3].behalf.lastName.val}}   • {{relationshipOptions?.filter(r => r.Value == steps[3].behalf.relationship.val)[0].Name}}

Additional people attending counselling

Please list additional people who may participate in counselling below

Please list people who may participate in counselling below.

{{attendee.firstName.val + ' ' + attendee.lastName.val}}   • {{relationshipOptions?.filter(r => r.Value == attendee.relationship.val)[0].Name}}
Add another person

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. Counselling Alberta 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.

Is there a concern about the use of any of the following?
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


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  
Registering on behalf of a child under 18
{{steps[1].behalfForChild.val ? 'Yes' : 'No'}}
Your first name
Your last name
Your Email Address
Email opt-in
{{steps[1].behalfOptIn.val ? 'Yes' : 'No'}}
Your relationship to the client
{{relationshipOptions.filter(c => c.Value == steps[1].behalfRelationship.val)[0].Name}}
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  
First Name
Last Name
{{genderOptions.filter(c => c.Value == steps[1].gender.val)[0].Name}}
Date of Birth
Email Address
Email opt-in
{{steps[1].emailOptIn.val ? 'Yes' : 'No'}}
Contact preference
{{steps[1].contactAt.val + (steps[1].discreetMsg.val == true ? ', discreet messages' : '')}}
{{ 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
Emergency Phone Number
Treaty Status
{{steps[1].isTreatyStatus.val ? 'Yes' : 'No'}}
Band Name
Treaty Number
Veteran Status
{{steps[1].isVeteran.val ? 'Yes' : 'No'}}
Reasons for Counselling  
What is bringing you in?
Counsellor preferences
How long has this been a problem?
{{problemLengthOptions.filter(c => c.Value == steps[2].problemLength.val)[0].Name}}
Has this situation been getting worse?
Interested in counselling for


My partner and I

My family

My Child/Children


My preference for counselling is:

In Person


My availability for counselling is:





Referred by
{{referralOptions.filter(c => c.Value == steps[2].referredBy.val)[0].Name}}
Family & Household  
Marital status
{{maritalStatusOptions.filter(c => c.Value == steps[3].maritalStatus.val)[0].Name}}
Employment status
{{employmentOptions.filter(c => c.Value == steps[3].employmentStatus.val)[0].Name}}
Household income
Additional people attending counselling

{{person.firstName.val + ' ' + person.lastName.val}} • {{relationshipOptions.filter(c => c.Value == person.relationship.val)[0].Name}}

Insurance & Fees  
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  
Is English your first language?
{{steps[5].englishFirstLang.val == 'yes' ? 'Yes' : 'No'}}
What languages do you speak at home?
{{languageOptions.filter(x => x.Value == lang)[0].Name}}
Is anyone coming for counselling taking medication?

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


Concerns about alcohol, drugs, or gambling?


Concern about violence?

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


Concern about suicide?

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


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


Final Information  
How did you find out about us?
{{findOutOptions.filter(x => x.Value == steps[6].howFoundOut.val)[0].Name}}
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?

{{majorFactorOptions.filter(x => x.Value == steps[6].whyChoseCCC.val)[0].Name}}


Are you paying more than 25% of your take home pay for rent or mortgage payments?
{{moreThan25Rent.filter(c => c.Value == steps[6].moreThan25Rent.val)[0].Name}}
Ethnic background

{{ethnicityOptions.filter(x => x.Value == steps[6].ethnicity.val)[0].Name}}


Highest level of education
{{educationOptions.filter(x => x.Value == steps[6].education.val)[0].Name}}
Were you born in Canada?
{{steps[6].bornInCanada.val == 'yes' ? 'Yes' : 'No'}}
Are you a farmer or member of a farm family?
{{steps[6].farmFamily.val == 'yes' ? 'Yes' : 'No'}}
Visible minority?
{{steps[6].isMinority.val == 'yes' ? 'Yes' : 'No'}}
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}}


Online Registration Form