Adult Counselling Intake Form

Fill in this form if you would like to access adult counselling services. This includes individual therapy, relationship/couples therapy, and family therapy.

Counselling services are available to residents of Alberta by default and some team members can offer counselling for residents of Newfoundland, Manitoba, Saskatchewan, British Columbia, Nunavut, Northwest Territories, and Yukon.

Basic Information

First name*

Last name*

Phone number

Email*

What province are you located in?*

What are you looking to work on?*

Anxiety

Depression

Family Therapy

Health Issues

Neurodiversity

Parenting Support

Couples/Relationship Therapy

Religion/Religious Trauma

Academic Struggles

Self-Esteem

Sexual Issues

Self-Improvement

Trauma

Work Stress

Body Image

Grief/Loss

Identity Exploration

Cultural/Racial Experiences

Burnout/Stress Management

Gender Identity or Sexuality

Addiction

Other

Is there anything else you'd like us to know?

Would you like to work with a therapist online or in-person?*

Do you have a strong preference for the gender of the therapist you work with?*

Are you looking for services in a language other than English? If so, please choose an option below.

Are you hoping to book with a particular counsellor? If yes, please select from the list below. Please note, requesting a specific counsellor does not guarantee availability. If they are unavailable, you will be contacted and offered another option.

Fees

Our standard fee is $235 per hour, which is aligned with the fee schedule set by the Psychologists' Association of Alberta (PAA).

If you need a fee other than $235 we are happy to help you. Everything we do is offered on a pay what you can basis.

We will never ask you to disclose your financial information or the reason you need a fee other than $235, however, we do expect clients to choose their fee honestly and to disclose and use any access to funding such as insurance coverage or FSCD funding.

Being honest with yourself about what fee you can afford shows that you value the services you are accessing and shows respect for the sustainability of our pay what you can approach and to all others who need access to lower fees too.

**Please declare the highest possible fee you can afford without compromising your financial stability.***

Do you have access to private insurance coverage, FSCD funding or anything else that can increase your affordability?*

yes

If yes, please list below:

Statement of Understanding

Please read the following statement of understanding and select the “I agree” box to complete the intake process.

I understand that accessing services at Cultivate comes with a commitment to participate in the sustainability of their pay-what-you-can approach. By completing this intake request, I understand that:

I am expected to choose the highest possible session fee I can afford without sacrificing my financial stability. I am expected to disclose access to any funding or insurance that will improve affordability or cover any portion of my services.

If my financial situation changes for better or worse, I am expected to proactively request a change in my fee.

There is high demand for services at Cultivate, and I am expected to adhere to the no-show and late cancellation policies of my therapist. I will respect my therapist’s time and the people waiting for a spot with them by giving the required notice to change or cancel an appointment.

I am expected to pay my invoices promptly. I will make sure that the payment method on file is valid, and if I need to change how I typically pay, I will inform my therapist in session.

My therapist will revisit my selected fee every 3 months. I am not expected to change my fee if I am unable, but I will be honest about fee changes if they can be made.

By ticking this box, I agree to the above statement and understand my responsibilities when accessing services at Cultivate.