Aulneau Renewal Centre
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Contract Counselling Intake
To be completed by Organization Seeking Service
Organization Information
Organization or Agency
*
Billing Address
*
Street Address
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Billing Phone Number
Worker/Advocate Name
*
First
Last
Worker/Advocate Phone Number
*
Worker/Advocate Email
*
Participant Information
Type of Service Requested At This Time
*
Individual Child/Youth
Individual Adult
Dyadic Caregiver/Child
Couples
Family
Parent Coaching
Dragonfly
Participant Name
*
First
Last
Participant Birthdate (Day, Month, Year)
*
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Address
*
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Participant's Gender
*
Partner's Name
*
Partner's Birth Date
*
Day
1
2
3
4
5
6
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Month
1
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Year
2026
2025
2024
2023
2022
2021
2020
2019
2018
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2016
2015
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2012
2011
2010
2009
2008
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1920
Partner's Primary Phone Number
*
Partner's Primary Email
*
Is the child in care?
*
Yes
No
Reason for original apprehension (if applicable)
How many placements has the child been in? (if applicable)
Years with current family (if applicable)
Current caregiver and child's relationship strength's & weaknesses (if applicable)
Difficult behaviour's appear at? (if applicable)
Home
School
Other
Caregiver Name(s)
*
Caregiver's Relationship to Child/Youth Participant
*
Biological Parent
Foster Parent
Relative
Participant/Caregiver Primary Phone Number
*
Participant/Caregiver Secondary Phone Number
Participant/Caregiver Email
*
Participant's Primary Address
*
Street Address
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Reunifying Caregiver's Name
*
First
Last
Reunifying Caregiver's Birthdate
*
Day
1
2
3
4
5
6
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10
11
12
13
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27
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29
30
31
Month
1
2
3
4
5
6
7
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9
10
11
12
Year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
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1959
1958
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1941
1940
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1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Reunifying Caregiver's Address
*
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Reunifying Caregiver's Phone Number
*
Reunifying Caregiver's Email
Does the child have a pre-existing relationship with the reunifying caregiver?
*
Yes
No
What is the frequency of current in-person visits between child and reunifying caregiver? (How often per week)
*
Please enter a number from
0
to
7
.
Is there room to increase visits to 2 times a week, 2 hours per visit?
*
Location Requested for Counselling Services
*
Winnipeg
Steinbach
Other
Language Preference for Services
*
English
French
Type of Counselling
*
Play Therapy
Drama Therapy
Music Therapy
Verbal Psychotherapy
EMDR
Type of Counselling
*
Play Therapy
Verbal Psychotherapy
EMDR
Is the participant currently having thoughts of and/or actively harming themselves?
*
Yes
No
Unknown
First Concern to be Addressed in Counselling
*
Second Concern to be Addressed in Counselling
*
Third Concern to be Addressed in Counselling
*
Participant's Strengths & Other Resources
*
Desired Outcomes/Changes for Participant (e.g., Goals for Therapy)
*
Diagnoses - Suspected or Confirmed
Any Additional Information?
Additional Documents (eg. Case Reports; Clinical Reports; Psych Assessments; School Assessments; Social History)
Drop files here or
Select files
Max. file size: 64 MB.
Accessibility
Please indicate any accessibility needs you have that we should be aware of when accessing services at our centre.
Terms of Service
*
I acknowledge and confirm that I have read the
Terms of Service
.
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