Step 1 of 4 25% 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/we have difficulty in relationship(s) I/we have experienced infidelity I have had a traumatic experience (recently or in the past) I’m feeling depressed or down I feel lonely I’m having trouble sleeping I’m dealing with stress at work or school I am dealing with grief or loss I want to discuss sexual orientation and/or gender identity My anger is problematic I am worried I am addicted to substances or a behaviour I have chronic pain or disability I/we are dealing with family matters I/we have parenting challenges I am facing transition issues (starting school, new work, moving household, and/or retiring, etc). I have self-esteem issues I struggle with my body image and/or eating habits Other Please specifyHow 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 specifyWhen 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 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 specifyI 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 specifyWhat is your preferred method of counselling?(Required) Online In-Person Option for both What is your desired municipality?When are your ideal times for appointments?(Required) Daytime Evenings Weekends How quickly do you wish to start counselling:(Required) As soon as possible In the next few weeks. No rush, I’m just curious what is available We can send you free useful tips to enhance your outlook on life. Interested?(Required) Yes No What topics are you interested in?What are the first 3 digits of your postal code I would prefer my counsellor to be:(Required) Female Male Doesn’t matter What gender do you identify with?(Required) Female Male Non-binary Other Prefer not to answer What is the age of the person seeking counselling?(Required) Under 12 12 – 18 19 – 25 26 – 35 36 – 50 51 – 65 65+ These optional questions will 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.This field is hidden when viewing the formSummary
