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. Please provide us with the following contact information:Address Street Address City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Primary Phone Number**Phone TypeCell PhoneHome PhoneWork PhoneSecondary Phone NumberPhone TypeCell PhoneHome PhoneWork PhoneAre 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. 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?