Aulneau Renewal Centre Aulneau Renewal Centre
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Register for Counselling

Completed by Individual Seeking Service

Step 1 of 8

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  • Questions followed by an * are required
  • Guardianship

    If the client is a minor, please fill out the section below. Please note that only a legal guardian is able to apply for services on behalf of the child. If there is a joint custody arrangement of a minor, we will require signed authorization from both caregivers before counselling services can begin. The required documents will be provided to the registering caregiver upon intake.
  • If you are creating this application for a child in your care, please indicate the present guardianship & custody arrangements.
  • Please Note: If you are a caregiver applying on behalf of a child and have arranged joint custody we will require further documentation which will be sent to you upon the approval of this application.
  • If you are creating this application for a child in your care, please indicate your relationship to the child
  • ARC is aware that there are limited resources in the community which are equipped to address situations where clients are involved in high-conflict separation or divorce proceedings. Unfortunately ARC is not equipped to fully support clients in all of the needs they may have in such situations. For this reason, ARC reserves the right to deny or terminate services where there are high-conflict divorce or separation legal proceedings underway. Please Note: Aulneau Renewal Centre employees cannot become involved in any active court proceedings on a clients behalf.
  • ARC is aware that there are limited resources in the community which are equipped to address situations where clients are involved in high-conflict separation or divorce proceedings. Unfortunately ARC is not equipped to fully support clients in all of the needs they may have in such situations. For this reason, ARC reserves the right to deny or terminate services where there are high-conflict divorce or separation legal proceedings underway. Please Note: We cannot provide services for families that are currently involved in legal custody disputes.
  • Please check all categories that best identifies the person for whom counselling services are requested.
  • Please provide us with some basic information about the child/youth who will be attending therapy with you. Please note that only a legal guardian can apply for Dyadic Parent/Child therapy. If there is a joint custody arrangement of a minor, we will require signed authorization from both caregivers before counselling services can begin. The required documents will be provided to the registering caregiver upon intake.
  • Date Format: DD slash MM slash YYYY
  • Please indicate your relationship to the child/youth who will be attending therapy with you.
  • Please indicate the present guardianship & custody arrangements you have with the child/youth who will be attending therapy with you.
  • Please Note: If you are a caregiver applying on behalf of a child and have arranged joint custody we will require further documentation which will be sent to you upon the approval of this application.
  • ARC is aware that there are limited resources in the community which are equipped to address situations where clients are involved in high-conflict separation or divorce proceedings. Unfortunately ARC is not equipped to fully support clients in all of the needs they may have in such situations. For this reason, ARC reserves the right to deny or terminate services where there are high-conflict divorce or separation legal proceedings underway. Please Note: We cannot provide services for families that are currently involved in legal custody disputes.
  • Family therapy may include up to 3 or more family members. This approach is appropriate for all ages.
  • Please provide us with some basic information about up to 3 of the other family member(s) who will be attending family therapy with you.
  • Play Therapy (children 12 and under): Play therapy involves using play as a means to build relationship, gather objective information, and process difficult events/situations. This approach is most appropriate for children 12-years and younger.
  • Drama Therapy (all ages): Drama Therapy uses active, drama interventions to build relationship, process difficult events/situations, and support neural integration. This approach is appropriate for individuals, dyads, and groups of all ages.
  • Music Therapy (all ages): Music Therapy uses active, music interventions to build relationship, process difficult events/situations, and support neural integration. This approach is appropriate for individuals, dyads, and groups of all ages.
  • Verbal Psychotherapy (adolescents and adults): Verbal psychotherapy uses talking to develop insight, and express & process difficult events/situations. Verbal psychotherapists may also use other mediums when working with clients (eg. Information handouts, drawing, breathing exercises, etc.). This approach is appropriate for adolescents (13-years and older) and adults, and can be used with individuals, dyads, and families.
  • Eye Movement Desensitization and Reprocessing (EMDR) therapy is an approach that is used to treat a wide array of presenting concerns, most notably concerns related to trauma. Please ask your clinician for more information regarding this type of therapy.
  • Do you require to work with a clinician of a particular gender?
  • Please Note: If you have been referred to Aulneau from Family Conciliation, you are required to submit to us a copy of all documentation from their agency before your application for services will be considered.
  • Please indicate any accessibility needs you have that we should be aware of when accessing services at our centre.
  • Please Note: The Aulneau Renewal Centre is committed to a positive environment in which all employees and clients are treated with compassion, respect, and dignity. Abuse and harassment in any form (verbal, emotional, physical or sexual) will not be tolerated and may result in a termination of services. We reserve the right to refuse services.
  • Thank you for providing us with that information. The following questions are to help us understand your reasons for requesting therapy at this time so that we can match you with the best fitting therapist for your needs.
  • If you are in crisis and need to speak to someone, you can call the Klinic Crisis Line at 204-786-8686. If you are struggling with thoughts of harming yourself or others please call The Crisis Response Centre at 204-940-1781.
  • Please list up to 3 of your greatest concerns that you would like to address in counselling at this time.
  • At Aulneau we strive to support wellness from a whole-person/holistic perspective. What do you hope will change in the following areas as a result of coming for counselling?
  • Financial Information

  • Thank you for your application! The next step is for us to determine your rate for services and method of payment.
  • Presently, Aulneau does not offer direct-billing to insurance providers. This means that you will be required to pay for the value of the session at your appointment, and then submit your receipt to your insurance provider for reimbursement. This out of pocket expense will be $110.00. - You will be responsible to submit your receipt top your insurance company - You are also responsible for keeping track of your coverage amount - Please let reception know when your coverage has been exhausted *This is not the same for Jordan's Principle, your file will be sent to the contract intake coordinator and they will get the required paperwork organized to send off.
  • If you are not using insurance, or will be using our sliding scale fees to cover the cost of sessions, your fees for service will be assessed based upon your household income and the number of dependents living with you.
  • Please Note: Aulneau does not presently have these professionals on staff.
  • Thank you for providing the above information. To determine your session rate, you will be required to submit documentation verifying your household income. This documentation may include a Notice of Assessment, an EIA budget letter, or a letter from your employer. Please submit this information to our Intake Coordinator at counselling@aulneau.com Please Note: Just as our clients reserve the right to terminate services, the Aulneau Renewal Centre (ARC) also reserves the right to terminate or deny services. There may be many reasons why ARC determines that we will need to deny or terminate services. In general, ARC strives to ensure that all of our services are professional and an appropriate fit for the needs of our clients. In situations where our ethics may be compromised--or where clients' needs extend beyond the services we are equipped to offer--we will refer to other agencies who are better equipped to support your needs.
  • Terms of Service

  • Aulneau Renewal Centre is currently experiencing a waitlist for services. Our Intake Coordinator will be in touch with you via email once your application for services is received. It is highly recommended that you monitor your emails (including your spam folder) for communications on the next steps in the intake process. In the meantime, please ensure that your financial information is submitted to counselling@aulneau.com

Aulneau Renewal Centre

228 Hamel Avenue Winnipeg, MB R2H 0K6
204-987-7090 - reception@aulneau.com

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