Counselling Inquiry Form

Thank you for your inquiry. You can take the next steps toward receiving counselling by completing this registration form. This form provides us with essential preliminary information; it also helps us to match your need to our services and to arrive at the fee we will charge for the session. The questions about household income are necessary as our fees are geared to income and the number of people dependent on that income.

If you would prefer to speak to us by phone, please call (613) 699-1677.

"*" indicates required fields

Name*

First Last

First and last name of spouse (if applicable)

First and last name of child if you are requesting counselling for a child

Age(s)

Confidential telephone number - I can be contacted at this number without confidentiality concerns*

Alternate telephone number

Email address - I can be contacted at this number without confidentiality concerns

Type of counselling required*

Individual

Couples

Family

Primary need for counselling - please provide a brief description of the reason(s) for which you require counselling*

Household income - total gross income of all employed persons in the household

Number of dependants

Do you have insurance that covers counselling?

Yes

When would you like to begin counselling?

When will you be available? (Sessions usually last 50 minutes to an hour)

My most convenient time is:

Phone

This field is for validation purposes and should be left unchanged.

Counselling Inquiry Form

How to Get Started

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About the name Elim

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