Client Intake Form: Find the Right Support

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Before We Get Into Your Details: Do You Need Immediate Support?* This field is required.If you are in immediate danger, experiencing a crisis, or feel unsafe, please call 911 or seek help at the nearest hospital before completing this form.
No
I’m not sure
Yes
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Share your details with us, and we'll help connect you to urgent support as quickly as possible.
First Name *     Last Name *
Email *
Phone Number *
City
Province
I am not in immediate danger or crisis.     I am in an emergency situation and need immediate support.               I need urgent support and would like to be connected with a counselor.     I can be reached by email.     I can be reached by phone.
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Tell Us About Yourself
Contact Information
First Name * Last Name *

Email * Phone Number *
City * Province *

Which age group describes you?
Under 18     18–24     25–39     40–59     60+ *

Preferred method of contact?
Email     Phone     Text/ SMS *

Can we leave a message on your voicemail?
Yes     No     Yes – leave a brief/neutral message (for shared voicemail) *
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Who will Be Participating in Counselling?
Just me (Individual counselling)
Me and my partner (Couples counselling)
Me and my partner (Parental counselling)
Me and my partner (Parental counselling)
Me and my partner (Parental counselling)
My family member(s) and I (Family counselling)
My child (youth counselling)
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What Kind of Support are You Seeking Right Now?Select all that apply
Specialized Assessments
Emotional & Mental Health Support
Addiction & Recovery Support
Greif & Loss Support
Trauma Support
Relationship & Family Support
Career & Workplace Support
Life Events & Transition Support
Women's Mental Health Support
Eldercare
Gender Affirming Care
Health & Coping Support
I’m unsure and would like to see all available support options.
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Specialized AssessmentsPlease select any services you would like to receive. If you’re unsure or none apply, you may skip this page and continue.
Mental Heath Assessment
Vocational Assessment
Addiction/Substance Use Assessment
Trauma Assessment
Other
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Emotional & Mental Health SupportSelect any concerns you would like help addressing. If you’re uncertain or none apply, you may skip this page and continue.
Anxiety and panic
Depression and low mood
Anger and emotional regulation
ADHD and focus challenges
Obsessive or intrusive thoughts
Stress or burnout
Self-esteem or confidence
Sleep disruption or fatigue
Social connection and loneliness
Other
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Addiction & Recovery SupportSelect any concerns you would like help addressing. If you’re uncertain or none apply, you may skip this page and continue.
Alcohol use concerns
Drug use concerns
Harm reduction approaches
Relapse prevention
Family and loved ones support
Recovery, maintenance, and stability
Other
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Grief & Loss SupportSelect any concerns you would like help addressing. If you’re uncertain or none apply, you may skip this page and continue.
Grief and bereavement (loss of a loved one)
Sudden or traumatic loss (illness, accident, workplace incident, etc.)
Trauma and PTSD
Divorce or relationship loss
Job loss (laid off, company downsizing, contract concluded, position eliminated, etc.)
Complicated or prolonged grief
Anticipatory grief
Other
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Trauma SupportSelect any concerns you would like help addressing. If you’re uncertain or none apply, you may skip this page and continue.
Recent traumatic event
Workplace critical incident
PTSD symptoms
First responder or frontline exposure
Historical or childhood trauma
Sexual trauma
Other
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Relationships & Family SupportSelect any concerns you would like help addressing. If you’re uncertain or none apply, you may skip this page and continue.
Communication challenges
Conflict with partner or family
Parenting challenges
Separation and relationship transitions
Caregiving stress
Blended family challenges
Intergenerational conflict
Other
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Career & Workplace SupportSelect any concerns you would like help addressing. If you’re uncertain or none apply, you may skip this page and continue.
Career exploration, role alignment, and goal setting
Identifying strengths, transferable skills and professional goals
Preparing for new roles, promotion, or career pivots
Navigating career transitions following health, life or workplace changes
Building confidence, clarity, and readiness for next steps and opportunities
Other
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Life Events & TransitionsSelect any concerns you would like help addressing. If you’re uncertain or none apply, you may skip this page and continue.
Life transitions or major changes
Feeling overwhelmed or directionless
Adjustment to illness, injury, or caregiving
Identity or role changes
Other
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Women's Mental HealthSelect any concerns you would like help addressing. If you’re uncertain or none apply, you may skip this page and continue.
Fertility, pregnancy, and reproductive loss
Perinatal and postpartum emotional support
Menopause and hormonal transitions
Caregiver stress and emotional overload
Chronic illness, pain, or health-related anxiety
Trauma, grief, and identity changes across life stages
Other
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Eldercare SupportSelect any concerns you would like help addressing. If you’re uncertain or none apply, you may skip this page and continue.
Emotional support for aging-related transitions
Coping with loss, grief, or declining independence
Caregiver stress, burnout, and role strain
Adjustment to illness, cognitive changes, or mobility loss
Family communication and planning support
Mental health support for older adults
Aging-related transitions
Dementia or memory-related support
Other
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Gender Affirming CareSelect any concerns you would like help addressing. If you’re uncertain or none apply, you may skip this page and continue.
Gender identity support
Gender exploration
Transition support
Gender dysphoria support
Support for hormone therapy
LGBTQ+ affirming support
Identity-related stress
Emotional support related to gender
Support with coming out
Workplace transition support
Other
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Health & Coping SupportSelect any concerns you would like help addressing. If you’re uncertain or none apply, you may skip this page and continue.
Sleep difficulties
Chronic stress or pain
Substance use concerns
Anger or emotional overwhelm
Other
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Do You Have a Preferred Practitioner?
Please Select
Please Select
No preference – please recommend a practitioner
Anthony Berger MA, C.C.C
Amanda Ross, MSW, RSW
Barbara Veder MSW, RSW
Bernard Blais Psychologue
Brittany Redman MSW, RSW
Carole Neron MSW, RSW
David Boudrea MSW, RSW
Fabiola Franco Fernandez R.Psych.
Gwen Kakouris OT
Heather Harmony MSW, RSW
Jen Den Ouden RP, CCC
Josee Mirabella MSW, RSW
Judy Hayward MSW, RSW
Roxanne Derhodge RP
Stefania Bonanno MSW, RSW
Mary Sorobey R.Psych.
Marion Yoshida MSW, RSW
Monica Tan MSW, RSW
Milagros Martínez RCC
Mitch McGoey RP
Vera Chung MSW, RSW
Wendy Carmichael MSW, RSW
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Preferred Session Format
Virtual (Video/Online)     In-Person (Office-Based)     Telephonic (Phone-Based)
Preferred Session Language
English     French     Spanish        Other
Preferred Gender of Your Counsellor
Man     Woman     Non-binary / Gender diverse No preference
Preferred Appointment Time
Morning (Weekdays)    Afternoon (Weekdays) Evening (Weekdays)
Weekends Flexible / Anytime Works
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Are there any cultural, lived-experience, or personal preferences you’d like us to consider to better support you?This is optional. You can share preferences related to cultural background, lived experience, or anything else that matters to you. If nothing comes to mind, you may leave this blank.
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Thank you for taking this first step.

Our AVora Wellbeing care coordination team will review your submission and follow up with you soon to discuss next steps.
Should be Empty:

Share your details with us, and we'll help connect you to urgent support as quickly as possible.

Tell Us About Yourself

Who will Be Participating in Counselling?