1-1 Counselling - Guardians families

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Important Disclaimer: * This field is required.This is not a service meant for immediate crisis situations. If you are currently experiencing thoughts of self-harm or suicide, or if you need urgent support, we encourage you to reach out to a crisis helpline. You can call or text 988 for immediate crisis support across Canada. Your safety and well-being are our top priority.
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What would you like to focus on in therapy?(multi-select)
Addiction or substance use
Trauma or PTSD
Family
Depression
Anxiety
Relationships and communication
Stress or burnout
Eating or body image concerns
Life transitions or major changes
Grief and loss
Other
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How intense or disruptive are these issues in your life right now? (Single choice)
Mild – It’s manageable, but I’d like support
Moderate – It impacts my day-to-day somewhat
Severe – It’s interfering with my life significantly
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How often do you use drugs or alcohol?
Never
Sometimes
Often
Almost Always
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Have you been formally diagnosed by a healthcare provider with any of the following conditions?(multi-select)
No formal diagnosis
Abuse (physical, emotional, or sexual)
Anxiety Disorder
Depressive Disorder
Adjustment Disorder
ADHD
Behavioural or substance use addictions
Bipolar Disorder
Borderline Personality Disorder
Chronic illness or chronic pain
Eating Disorder
Narcissistic Personality Disorder
OCD
Postpartum depression or anxiety
Sexual dysfunction or disorder
Sleep disorder
Other
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Do you currently take prescribed medication for any of the conditions selected?
YESNO
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If yes, what is the name of the prescribed medication?
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Have you had therapy or treatment before?
YESNO
9
If yes, when and for how long?
10
Have you been to inpatient treatment before?
YESNO
11
If yes, when and for how long?
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What are your preferred pronouns? (multi-select)
She/her/hers
He/him/his
They/them/theirs
Any/all
Prefer not to answer
13
In the past two weeks, which of the following areas have you been most concerned about?(multi-select)
Personal Well-being: Physical health, mental health, or self-care
Family & Close Relationships: Issues with family members, a loved one or close friends
Social & Professional Life: Challenges at work, school, or with friends
Overall Well-being: Your general sense of happiness, balance, or life satisfaction
Financial Stress: Money, debt, or budgeting concerns
Addiction or Substance Use: Concerns related to substance use or addictive behaviors
Parenting & Caregiving: Challenges related to caregiving, children, or dependents
Other
14
Do you currently have a reliable support network?
YESNO
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What's your name?* This field is required.
First Name
Last Name
16
What's your date of birth?
Date
Month
Day
Year
17
What's your email?* This field is required.
example@example.com
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Phone Number* This field is required.
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What's the best way to reach you?
Phone Call
SMS
Email
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Where do you live?
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland
Nova Scotia
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Northwest Territories
Nunavut
Other
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What is your preferred language for therapy?
EnglishFrench
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Do you want to tell us anything else about what you're looking for today?
Huge
Large
Normal
Small
Ok
Ok
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Terms and Conditions* This field is required.Your privacy is important to us. The information you share is available only to those who need to know to provide advice and care. The privacy and confidentiality of the information collected is protected in accordance with the Personal Health Information Protection Act (PHIPA) and The Personal Information Protection and Electronic Documents Act (PIPEDA). Your information is stored securely using encrypted systems, and access is limited to authorized staff. We do not share your information with third parties without your explicit consent, unless required by law. You have the right to request access to, or correction of, your personal information at any time. You may also withdraw your consent where applicable, subject to legal and contractual limitations.
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Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
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Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
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Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
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Cook Islands
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Cuba
Curaçao
Cyprus
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Democratic Republic of the Congo
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Dominican Republic
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El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
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Guinea
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Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
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Jordan
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Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
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Paraguay
Peru
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Pitcairn Islands
Poland
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Vatican City
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Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Please give information about patients health.
Yes
No
Are you presently under medical care?
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Do you have any drug allergies?
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Do you have any food or environmental allergies?
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Have you ever had tuberculosis or had a positive tuberculosis test?
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Have you ever been cared for by a mental health clinician?
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Have you ever restricted your eating?
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Are you presently under medical care?
Do you have any drug allergies?
Do you have any food or environmental allergies?
Have you ever had tuberculosis or had a positive tuberculosis test?
Have you ever been cared for by a mental health clinician?
Have you ever restricted your eating?
Yes
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No
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Yes
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No
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Yes
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No
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Yes
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No
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Yes
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No
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Yes
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No
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