Step 1 of 5 20% Last Name What type of support are you looking for?(Required) Individual counselling Couples counselling Family counselling Child or youth counselling Of the following statements, select the top 5 that apply to your circumstances.(Required) I'm feeling anxious, stressed or panicky I often have negative thoughts I'm having difficulty in my relationship(s) I have had a traumatic experience (recently or in the past) I'm feeling depressed or down I experience loneliness I'm having trouble sleeping I'm dealing with stress at work or school I am dealing with grief or loss LGBTQ (Sexual orientation or gender identity issues) My anger is problematic My substance use is concerning (whether it be to others or to yourself) Chronic pain or disability Family matters Parenting Transitions, ie., starting school or new work, moving household/communities, or retiring etc. Self-esteem Body image Eating habits Other Please specify How have you been affected on a daily basis? Check all that apply.(Required) Low energy level No longer enjoying things that used to be fun Poor eating habits Not sleeping well Feeling irritable most of the time Poor relationships Problem with alcohol or drug use Poor physical health Other Please specify When did these concerns start to affect you and your life?(Required) Very recently Within the past 6 months 6 - 12 months ago Ages ago but it's time to really work on feeling better Help us understand how you have been feeling by rating how well you have been doing in the following areas of your life over the last week or two.How would you rate your general sense of wellbeing?How would you rate your general sense of wellbeing? (Required)How would you rate your individual/personal wellbeing?How would you rate your individual/personal wellbeing? (Required)How would you rate your close relationships (ie. family, partner)?How would you rate your close relationships (ie. family, partner)? (Required)How would you rate your social relationships (work, school, friendships)?How would you rate your social relationships (work, school, friendships)? (Required)How would you rate your level of stress (1 being low degree of stress, 10 being high degree of stress)?How would you rate your level of stress (1 being low degree of stress, 10 being high degree of stress)? (Required)How would you rate your level of sadness (1 being low degree of sadness, 10 being high degree of sadness)?How would you rate your level of sadness (1 being low degree of sadness, 10 being high degree of sadness)? (Required) Have you had counselling before?(Required) Yes No If "yes", please describe below if you found it helpful or not. If "no", why not?I'm looking for a counsellor who will (select the top 3):(Required) Teach me new strategies Assign me homework or reading Challenge illogical thinking or assumptions Explore my past experiences Teach me mindfulness Instill hope Not too sure Other Please specify I would prefer a counsellor with the following style: (select the top 3)(Required) Ask questions so I can reflect and explore what is going on with me Directly shares their insights and advice with me Challenges me to try new things or ways to see things that will help me grow Provides structured counselling sessions with homework and readings to complete Allows for a free flow of conversation, adjusting the strategies each time Not too sure Other Please specify If in-person counselling is not available, would you like to meet with a counsellor by phone or video?(Required) Yes No If in-person counselling is an option, what is your desired location? I would prefer my counsellor to be:(Required) Female Male Doesn't matter What is your gender?(Required) Female Male Non-binary Other Prefer not to asnwer What is your age?(Required) Under 18 18-30 30-45 45-65 65+ These next few questions will help us match you with a counsellor and help you get a “head start” on getting the results you want from counselling.What would you like to be doing differently in 6 months from now? How will you know that counselling has been worthwhile? Name a single, small action you can take that will improve things for you just a tiny bit. Looking back, what has worked for you before? How would you describe your support system? Who can you turn to? What can you do to get the ball rolling before you have your consultation with a counsellor? Name the top issue to focus on in counselling that will really make a difference. Untitled First Choice Second Choice Third Choice
