Intake Form – Counselling

Intake Form for Counselling

Illustration of a woman holding a large pencil on her shoulder with a giant clipboard beside her
Step 1: Intake Form

Intake Form

Fill out a short form telling us about yourself, and letting us know you’d like support. This gets sent to our Outreach Coordinator, who will contact you within 5 days to set up an appointment for your Screening Call.

Illustration of a woman and her thought bubbles displaying her different emotions
Step 2: Screening Call

Brief Screening Call

We’ll have a friendly conversation with you to understand your next steps. We’ll talk about your safety and how we can help you best. Our Outreach Coordinator will add you to our waitlist, share helpful resources and give you an idea of how long your wait time may be.

Our Outreach Coordinator will try to contact you within 5 days of getting your Intake form. Please try your best to get back to her within 30 days. If now is not the right time for you to start your counselling journey, that’s okay! For your privacy, after 30 days, your intake form will be destroyed. You can re-apply any time, and you can always reach out if you have any questions.

An illustration of an older woman sitting in front of a large calendar and phone with mountains in the background
Step 3: Staying Connected

Staying Connected

While you wait for counselling, you can choose to have regular once a month check-ins with our Outreach Coordinator. You can also reach out any time with any updates or questions you may have.

An illustration of two women sitting across from each other talking
Step 4: Counselling Sessions

Counselling Sessions Begin!

When a counsellor has space for new clients, they’ll contact you to schedule an Intake Session. This will be the first session in your counselling journey!

Intake Form – Counselling

By completing this intake form, you are agreeing to the following confidentiality policy:

My involvement with the Stopping the Violence Program is voluntary and confidential within the limits of the law. I understand that confidential services mean that a release of any information may only happen with my written consent and that the Stopping the Violence Counsellor may not legally or ethically discuss any details of my session either personally or professionally. The following situations are exceptions: if the client is a risk to herself or another person; if the client’s life is at risk; if a child is at risk; if a court order is issued for the counsellor’s records, or; for purposes of supervision, and for case consultation within Fernie Women’s Centre staff team.

If we can’t reach you for a screening call within 30 days of attempted first contact, your data and intake form will be destroyed.

Address
Address
City
State/Province
Zip/Postal
Country
How would you like us to contact you? (you can check more than one)
Is it safe to leave a text/voicemail message? (you can check more than one)
Where would you prefer to receive counselling? (you can check more than one)
What days can you attend counselling? (you can check more than one)
Is there a counsellor you would prefer to see? (you can check more than one)
We will only call in the event of a medical emergency.

Safety

Are you feeling safe in your current relationship?
Have you recently separated, or are you considering separating, from an unsafe relationship?
Have you ever experienced sexual assault?
*There are many forms of sexual assault, all of which includes any unwanted touching, forced kissing, or forced sex. If you are unsure, select ‘Ever’ and provide details below
Have you had thoughts of suicide?
Have you attempted to end your life?

Health Information

Do you have access to extended health benefits or EAP?

Counselling History and Goals

Are you currently attending counselling with another provider?

Resources