Intake Form

The fill out the intake form below, giving us as much detail as possible. This will help us connect you to the best counsellor for your needs.

Your First and Last Name (For couples please include partner's full name)(Required)

Email Address(Required)

Cellphone Number(Required)

May we leave a voicemail message on your cellphone?

Yes

Work Phone Number(Required)

May we leave a voicemail message on your work phone?

Yes

Your Mailing Address

Do you have a preferred pronoun?

Family Doctor:

Family Doctor Contact (can we contact them to introduce our services?)

How did you hear about Ealing Counselling & Coaching? Please be specific i.e Google, Yelp, Friend, Doctor, etc.

Please list any medical issues that we need to be aware of:

Please list any medications you are taking:

Please describe any other therapy, treatment or counselling sessions you are attending:

Do you have coverage through an Extended Health Care Plan?

If Yes, Which designation does it cover? Social Worker or Counsellor (we do not have Psychologists). We must know this before being able to schedule an appointment.

Which counsellor would you like to book with?

If you are seeking counselling as a result of a car accident, please provide your ICBC Claim Number:

If you are seeking counselling via the Crime Assistance Program (CVAP), please provide your claim number:

Briefly describe why you are seeking counselling.

I have read and agreed to the following cancellation policy at the bottom of this page(Required)

Yes

As we may receive multiple intakes daily, please allow for a minimum of 24 business hours for a response as we process the intakes in the order they are received.

Cancellation Policy:

A valid credit card is required on file in order to book in for counselling sessions.

For appointment cancellations, a minimum of 48 hours notice must be provided by email to info@ealingcounselling.ca or by voicemail. If an appointment is cancelled with less than 24hrs notice, you will be required to pay 100% of your session fee.