Counsellor Intake Form

Personal Details

Only your name will be visible to your clients
Title
Name*

First NameLast Name
Pronouns
Email*

Confirmation Emaile.g. you@email.com
MaleFemaleTransgenderNon-BinaryTwo- SpiritPrefer not to sayOther

Location Details
Street 1*
Street 2
City/Town*
Country*
Province/Territory*
Postal Code*
Timezone*
Business Email*
e.g. you@email.com
Fax Number
Office Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mobile Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
How did you hear about EaseCare?*
Other*
YesNo

Terms of Use

Professional Details 3/3

Could you please indicate the province(s) where you hold a professional license or registration? Also, please provide the respective regulatory authority and your license or registration number.
YesNo
Please input the details of your clinical supervision, such as the supervisor's name and their college registration number. These details will be reflected on the session receipts for clients who require this information*

Practice Details 1/6

Which language(s) are your comfortable providing treatment in?
EnglishFrench
Other languages

Matching Preferences

If you are interested in accessing new clients through Inkblot, we will need a photo and a profile description. Otherwise, skip this screen
Please upload a headshot that is friendly yet professional: .jpg, .jpeg, .png types allowed.*

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Could you provide an overview of your therapeutic approach and outline the potential benefits clients may experience during their therapy sessions with you?*
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Required Documents
Professional license/registration: .jpg, .jpeg, .png, .pdf, .doc, .docx types allowed.*

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Professional liability insurance: .jpg, .jpeg, .png, .pdf, .doc, .docx types allowed*

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Highest relevant degree: .jpg, .jpeg, .png, .pdf, .doc, .docx types allowed*

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If you have difficulty uploading any of these documents, please email them to support@easecare.ca
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Feel free to submit the form once you've ensured the information is correct and complete. If you need to make any changes or updates, simply use the "back" button to review and revise your entries.
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