Client Intake Form

Help us match you with the right counsellor for your needs.

Client Intake Information

Thank you for your interest in counselling services at the White Rock Counselling Cooperative. This intake form will help us understand your needs and match you with the most suitable counsellor. All information provided will be kept confidential and will only be used for the purpose of connecting you with appropriate services.

Personal Information

First Name *

Last Name *

Date of Birth *

Gender

Email *

Phone *

Address

City

Postal Code

Emergency Contact

Name

Relationship

Phone

Counselling Information

Presenting Concerns/Issues * Please briefly describe the main concerns that have brought you to seek counselling at this time.

Previous Therapy Experience If you have had previous counselling or therapy, please briefly describe when, for how long, and whether you found it helpful.

Counsellor Preferences

Specific gender preference

Specific therapeutic approach

Experience with specific issues

Specific language needs

Preference Details If you have specific preferences for a counsellor, please provide details here.

Scheduling & Insurance

Preferred Days for Appointments

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Preferred Times for Appointments

Morning (9am-12pm)

Afternoon (12pm-4pm)

Evening (4pm-7pm)

Insurance Information If you plan to use insurance to cover counselling services, please provide details of your coverage (provider, policy number, coverage amount, etc.).

Additional Information

Is there anything else you would like us to know?

How did you hear about us?

Consent

I consent to being contacted by the White Rock Counselling Cooperative regarding my intake information and appointment scheduling. *

I understand that the information provided in this form will be kept confidential and will only be used for the purpose of connecting me with appropriate counselling services. *

What Happens Next?

1. Review

After submitting your intake form, our team will review your information to understand your needs and preferences.

2. Matching

We'll match you with a counsellor who has the expertise and availability to meet your specific needs.

3. Contact

Within 2 business days, you'll be contacted by either our intake coordinator or your matched counsellor to schedule your first appointment.

If you have any questions about the intake process, please don't hesitate to contact us.