Intake Survey

Personal Information


Contact Information

General Information

On a scale of 1-10 how committed are you to working on these concerns?
What format of counselling would you prefer (check all that apply)
Preferred appointment times and days preferred (check all that apply)
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 $40 per 60 minutes session.)


Fee Calculator


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 If the applicant is under the age of 18, parent(s) proof of income will be required.


Extended Health Coverage (please check appropriate box)



Registered Charity

South Island Centre is a Registered Canadian Charity


©2020 by South Island Centre for Counselling and Training Society | Charity Registration Number 896568417RR0001