Where are you requesting services?*

Winnipeg
Steinbach

What type of services are you requesting?*

Please provide your partner's name.*

First Last

Please provide your partner's gender.*

Please provide your partner's pronouns.

Please provide your partner's birth date.*

Please provide your partner's address (if different from the address provided above).

Street Address City State / Province / Region ZIP / Postal Code

Please provide your partner's primary phone number.

Please provide your partner's email.

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.

Family Member 1

First Last

Birth date of Family Member 1

Your Relationship to Family Member 1:

Family Member 2

First Last

Birth Date of Family Member 2

Your Relationship to Family Member 2:

Family Member 3

First Last

Birth Date of Family Member 3

Your Relationship to Family Member 3:

What type of Therapy are you requesting?*

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.

Music Therapy & Expressive Arts Therapy (all ages): Music & Expressive Arts therapy use the creative and expressive functions of the arts to build relationship and support the process of healing through emotional processing and neural integration using arts-based mediums. 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.

Family Therapy (all ages): Family therapy may use elements from any of the other pproaches with up to 3 or more family members. This approach is appropriate for all ages.

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.

Counsellor's Gender

Do you require to work with a clinician of a particular gender?

No, It does not matter
Male
Female

Language preference for services

Have you accessed services at Aulneau Renewal Centre before?*

Yes
No

How did you hear about Aulneau Renewal Centre?*

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.

Is your involvement with CFS related to a child in care?*

Yes
No

Please provide your Social Worker's name.*

First Last

Please indicate your Social Worker's CFS Agency.*

Please provide your Social Worker's phone number.*

Please provide your Social Worker's email.*

Accessibility

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.

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