Questions followed by an * are required
Who is this application for?*
- This is for myself
- This is a for a child in my care
Guardianship
If the client is a minor, please fill out below section. Please note that only a legal guardian is able to fill out the application for services on behalf of the client. Please note that if there is joint custody of a minor, we will require written permission from both guardians before counselling services can begin. If you are currently involved in divorce or separation proceedings we will not be able to offer you service.
Guardianship of the child*
If you are creating this application for a child in your care, please indicate your guardianship status
- Primary Care & Control
- Joint Custody
Relationship to the child*
If you are creating this application for a child in your care, please indicate you relationship to the child
- Biological Parent
- Foster Parent
- Relative
Primary Guardian's Name*
First Last
Primary Guardian's Phone Number*
Is it safe to leave phone a message?*
- Yes
- No
Primary Guardian's Email
Consent To Correspond Via Email?*
- Yes
- No
Is the child presently involved in any court proceedings for custody disputes?*
- Yes
- No
Please note: We cannot provide services for families that are currently involved in legal custody disputes.

Client's Name*
First Last
Client's Birthdate*
Gender*
Client's Primary Address*
Street Address Address Line 2 City Province Postal Code
Client's Primary Phone Number*
Is it safe to leave phone a message?*
- Yes
- No
Client's Secondary Phone Number
Is it safe to leave phone a message?
- Yes
- No
Client's Email*
Consent To Correspond Via Email?*
- Yes
- No

What do you do when you feel stressed or overwhelmed?
Who do you turn to when you need support?
What do you hope will change the most a result of coming for counselling?
How will you be able to tell when you won't need to continue coming for therapy?
How optimistic are you that your concerns can be resolved?
- Not Very Optimistic
- Somewhat Optimistic
- Optimistic
- Very Optimistic

Terms of Service
Terms of service*
- I acknowledge and confirm that I have read the Terms of Service.
Aulneau Renewal Centre is currently experiencing a 8-12 week waitlist. Our intake coordinator will be in touch with you as soon as a therapist is available to see you and set up your first appointment. In the meantime, please ensure that the financial information is submitted as this helps speed the process. If you would like to speed up the process, please submit your financial information to counselling@aulneau.com as soon as you can. This helps us process your request quicker and can help you see a therapist if one is available sooner. Please ensure that the client name is provided in the email with the financial information.
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Guardianship