CCO Intake Questionnaire Name* First Last Age RangeUnder 1818-2425-3435-4445-5455-6465 or AbovePrefer Not to AnswerNames of anyone to be included in the counselling sessionsIf there are any minors, please indicate their ages as well.Are you requesting individual, couple or family counselling?*Please choose oneIndividualCoupleFamilyWhat is the main reason you are seeking counselling? (Please be as specific as possible so that we can assign you to a therapist who will best be suited to help you with the issue.)*Have you had previous counselling with our organization?*Please choose oneYesNoWhich therapist did you see?*Please choose oneAlexiaBrandiBenChrisElizabethHeatherJenniferJoanneKimberleyLindsayMargieSaraOtherHow did you hear about Christian Counselling Ottawa?* Church A Friend Radio Advertising Web Search Other Are you interested in having prayer and/or Scripture as part of your counselling sessions?*YesNoDo you have a home church? If so, which one?Fee CalculationOur fees are calculated based on the following information:What is your gross household income?*Please choose one$20,000 or under$20,000 to $30,000$30,000 to $35,000$35,000 to $40,000$40,000 to $45,000$45,000 to $50,000$50,000 to $55,000$55,000 to $60,000$60,000 to $65,000$65,000 to $70,000$70,000 to $75,000$75,000 to $80,000$80,000 to $85,000$85,000 to $90,000$90,000 to $100,000$100,000 to $125,000$125,000 to $150,000$150,000 to $175,000$175,000 to $200,000$200,000 to $250,000$250,000 to $300,000$300,000 or overHow many people are living off that income?*Please choose a number12345678910 or moreDo you have health insurance that you plan on using to cover your counselling sessions?*Please choose oneYesNoI don't knowI want to use my EAP (Employee Assistance Program)More information about insurance coverage is available on request. PLEASE NOTE that using an EAP requires a referral from the employee's program. Contact your EAP representative for more information if you have not yet received this referral.AvailabilityPlease indicate your availability for counselling sessions.* Monday - Morning Monday - Afternoon Monday - Evening Tuesday - Morning Tuesday - Afternoon Tuesday - Evening Wednesday - Morning Wednesday - Afternoon Wednesday - Evening Thursday - Morning Thursday - Afternoon Thursday - Evening Friday - Morning Friday - Afternoon Saturday - Morning Saturday - Afternoon Mornings 9am-12pm | Afternoons 1pm-4pm | Evenings 5pm-8pmPlease identify your preferred location for counselling services. (PLEASE NOTE: Weekday Evening and Saturday appointments are only available at our Main Office location)*Main Office - 63 Glencoe St. (Hunt Club & Greenbank)Gloucester - Greenbelt Baptist ChurchKanata - Kanata Baptist ChurchDundas County - Williamsburg Christian Reformed ChurchDivisional Offices are available on the following days (please make sure your availability matches your preferred location): Gloucester (Tues) -- Kanata (Tues & Fri) -- Ottawa South (Thurs) -- Williamsburg (Thurs)Contact Information The intake team will contact you as soon as possible. Please provide us with the following contact information:Primary Phone Number*Phone TypeCell PhoneHome PhoneWork PhoneSecondary Phone NumberPhone TypeCell PhoneHome PhoneWork PhoneWhen is the best time for us to contact you?*Any timeMorningAfternoonEvening9am-5pmAre there any confidentiality concerns with leaving a message at either of those numbers?*No concernsOnly leave message with name and numberNo messagesEmail Address* We do not sell or distribute email addresses and you will not be added to any email lists.Please let us know your preferred method of contact*Please selectEmailPhoneAny concerns or extra notes?