Counselling Psychology Intake Form

If this is an emergency, do not fill out this form. In such a situation, please go to the nearest emergency room or call the Distress Centre 24-hour line at 403-266-4357 to speak with someone.

Please fill in the information required below. Once submitted, you will be contacted by one of our staff within 3 business days to set up an appointment time. The fee for counselling is $165 per 50-minute session.

Is the prospective client a current student in the Foothills Academy School program? If so, before you fill out this form, check with the classroom teacher to see if your child qualifies for counselling through the school program. If so, there is a different form to complete that the teacher can give you.

Your name

First NameLast Name

Address - Please note that we are only licensed to serve clients residing in Alberta

Street Address

Street Address Line 2

CityProvince

Postal Code

E-mail

Confirmation Email

Phone Number:

Area CodePhone Number

How did you hear about our counselling services at Foothills Academy's Community Services?

I/We are seeking:

Other

Client Name

First NameLast Name

Gender

Date of Birth

MonthDayYear

Age

Client's School (if relevant)

Client's Grade (if relevant)

Client Name 2

First NameLast Name

Gender

Date of Birth

MonthDayYear

Age

Client's School (if relevant)

Client's Grade (if relevant)

Client Name 3

First NameLast Name

Gender

Date of Birth

MonthDayYear

Age

Client's School (if relevant)

Client's Grade (if relevant)

Client Name 4

First NameLast Name

Gender

Date of Birth

MonthDayYear

Age

Client's School (if relevant)

Client's Grade (if relevant)

Client Name 5

First NameLast Name

Gender

Date of Birth

MonthDayYear

Age

Client's School (if relevant)

Client's Grade (if relevant)

What is the presenting concern for the client(s)?

What is the history of the presenting concern?

Has the client received counselling previously?

What would your goals for counselling be?

Please indicate your availability at the following times

Rows	Monday	Tuesday	Wednesday	Thursday	Friday
Daytime
Evenings

Fees and Financial Assistance:

The fees for counselling are $165 per 50-minute session.

Many private and employer benefit plans provide coverage for psychological services. It is recommended that parents/clients discuss their coverage with their insurer to determine whether our services will be covered. Counselling services are provided by Registered Psychologists or Registered Provisional Psychologists (who are supervised by a Registered Psychologist).

Please note: Any costs for such services as psycho-educational assessments, counselling, or consultation that are not reimbursed through insurance might be able to be claimed as a medical expense upon completing your income tax.

Foothills Academy Society is committed to making our services financially accessible (for youth and children only) by providing access to financial assistance on a sliding scale basis dependent on family income through a Bursary Fund. With the above information in mind (employer benefits and tax deductions), do you require a bursary application package?

In the past year, have any family members living in the same household received any bursary assistance? If so, please check all applicable programs a bursary was received for:

What is the name(s) of the person(s) the bursary was for?

Upon receipt of this intake form, you will be contacted by a psychologist to arrange a time for an appointment. The bursary documents are reviewed by our Bursary Committee as a separate process. If you need to wait for the Bursary Committee's decision prior to beginning counselling, please discuss your situation with the psychologist when he or she calls you for your appointment.