COUNSELLING REGISTRATION FORM

Please fill out this form completely and accurately. Your personal information will be kept confidential.

    PERSONAL INFORMATION

    Person 1:









    Reason for seeking Counselling Services:

    (please check all that apply)

    CONDITION

    HOW FREQUENTLY YOUR ISSUES OCCUR

    Received Counselling In the past?

    Mental Health or Medical (specify)

    Medications (specify)

    How Did You Hear about Us?

    Available Day/Time for Sessions

    Person 2:









    Reason for seeking Counselling Services:

    (please check all that apply)

    CONDITION

    Difficulty Controlling AngerAnxiety/DepressionRelationship IssuesAnger/AggressionDifficulty Managing StressSexual IssuesOther

    HOW FREQUENTLY YOUR ISSUES OCCUR

    Received Counselling In the past?

    Mental Health or Medical (specify):

    Medications (specify):

    How Did You Hear about Us?

    Available Day/Time for Sessions: