Intake Survey

Personal Information

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Contact Information

General Information

What format of counselling would you prefer (check all that apply)
Choose the days and times that you are available for counselling. Please choose carefully as these times/days will be used to set up your future appointments.
Presenting concerns, click all that apply:

Financial Information (proof of income may be required in the form of a tax assessment. The counselling rate will be calculated by multiplying Gross Annual Income by 0.1%. Our minimum fee is $50 per 60 minutes session.)

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Fee Calculator

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Gross annual income is shown on line 150 of your tax return. South Island Centre reserves the right to request formal documentation for proof of income. Applicants may be required to send proof of income to info@southislandcentre.ca. If the applicant is under the age of 18, parent(s) proof of income will be required.

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Extended Health Coverage (please check appropriate box)
Select an option

Methods of Payment

For any online counselling (video or phone) a credit card, visa/MC debit, google pay or apple pay will be required for payments. Your payment method must be set up in the Jane App system before your first appointment. All payments will then be processed at the end of each counselling session by your counsellor. We do not accept e-transfers. 

For in-person sessions we accept credit card, debit card, apple pay, google pay or cheque. 

Other

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