Confidential Consult Intake Form

(Two Minutes to Complete)

Dipping your toes into counselling - even in a small way - can feel unsettling.

That's normal. So - we want to support you in feeling as calm and grounded and relaxed as possible. That way, in the session ahead, you can explore and learn a bit and maybe get some sense of how counselling might help you out.

Filling out this Confidential Form gives us a little info about your preferences. Hopefully we can use it to set up a space for you where you feel at maximum ease...

What motivated you to book this consultation?

What motivated you?

I'd like some support with stress or overwhelm

I’m curious about trauma-focused counselling

I'd like to change how trauma symptoms complicate my life

I’ll wait to tell someone in person

Other

What kind of support tends to help you feel safe or grounded?

What helps you feel grounded?

A calm, steady presence

Clear structure and guidance

Space to talk about things I've kept to myself

Tools or practices to try

I’ll wait to tell someone in person

Not sure yet

Is there anything that would help your consultation feel more comfortable?

What makes you comfortable?

Going slowly

Not diving into personal history right away

Having a clear outline of what the session will involve

Space to ask questions

Nothing in particular

Not sure

Many people choose to pay for counselling by using their insurance. If that's your plan, please let us know the name of the insurance company or organization that would cover your costs. (Or let us know if you plan to pay out of pocket).

One last time, please submit your information to secure your appointment...

Your Name

First Name *

Last Name *

Your Best Email Address

Email *

Your Phone Number

Phone *

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