Hi There
- I'm Farah.
Let's get to know each other before our first session.
About You
First Name
Last Name
Date of Birth
January
February
March
April
May
June
July
August
September
October
November
December
Day
Year
Street Address
Postal Code
Email Address
Telephone Number
May we leave a voicemail?
Yes
No
About Counselling
What Would You Like Us To Talk About?
Your History With Counselling
(Optional)
List of Year, # Sessions, Why you sought counselling
What Have You Liked and Disliked?
(Optional)
Have your previous counselling experiences been positive or negative, and what have you particularly liked or disliked?
Any Alcohol or Drug Abuse?
(Optional)
Do you have concerns about alcohol use, drug abuse, or overuse of prescription or non-prescription drugs?
Concerns about violence?
(Optional)
Please list any concerns about violence by - or to - you or others.
Concerns of suicide?
(Optional)
If you are in crisis, please call the distress line at 403.266.4357
Anything else to tell me?
(Optional)
Would you like me to know anything else before our first session?
Availability for Counselling
Weekday Daytime
Weekday Evening
Saturday Daytime
Alberta Blue Cross
(Optional)
I can direct bill your Alberta Blue Cross plan. If you have one, please provide your details.
Group Number
(Optional)
ID Number
(Optional)
Save Your Spot
Your card is stored securely to save your session spot.
Your card will be used to both hold and provide payment for our sessions. As payment is processed in advance, please note that I require at least 48 hours' notice to cancel a session without being charged.