CCO Intake Questionnaire Name* First Last Names of anyone to be included in the counselling sessionsAge*Please choose one0-1213-1819-3031-4546-6060+Please provide the specific age of minors*Please enter a number from 0 to 19.Are you requesting individual, couple or family counselling?*Please choose oneIndividualCoupleFamilyAge of PartnerPlease choose one13-1819-3031-4546-6060+Age of Partner (if applicable)Please choose one13-1819-3031-4546-6060+Age of all children included in family counselling*What 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.)*Please let us know your preferred language for counselling.EnglishFrenchArabicHave you had previous counselling with our organization?*Please choose oneYesNoWhich therapist did you see?*Please choose oneAlexiaBrandiBriannaCallyCarolyneChristopherCorianderElizabethHeatherJenniferJoannaJoanneMargieMarie-RoseMichaelNicoleSandraOtherHow 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. *Please note that our fees will be increasing as of October 1, 2017 in accordance with our annual fee review*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- Please speak with Intake)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. (Availability is limited--we cannot always accommodate your preferred time so please indicate as much availability as possible. Evening and Saturday appointments will require a longer wait to see a counsellor.)* 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 Church - Available TUESDAY DAYTIME ONLYKanata - Kanata Baptist Church - Available TUESDAY / FRIDAY DAYTIME ONLYDundas County - Williamsburg Christian Reformed Church - Available THURSDAY AFTERNOON ONLYDivisional Offices are available on the following days (please make sure your availability matches your preferred location): Gloucester (Tues daytime ONLY) -- Kanata (Tues daytime / Fri afternoon ONLY) -- Williamsburg (Thurs afternoon ONLY)Contact Information The intake team will contact you as soon as possible. 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We do send appointment reminders if you consent to receive them.Do you consent to receive email reminders regarding your appointments? I agree Any concerns or extra notes?