Where are you requesting services?*

Winnipeg
Steinbach

What type of services are you requesting?*

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.

Child's Name

First Last

Child's Birth Date

Your Relationship to the Child

Please indicate your relationship to the child/youth who will be attending therapy with you.

Guardianship & Custody*

Please indicate the present guardianship & custody arrangements you have with the child/youth who will be attending therapy with you.

Child resides with both parents
Child resides with one parent [I have primary care and control]
Child resides in a joint custody arrangement
Child resides with other relative(s) or caregiver(s) [we/I have primary care and control]

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.

Is the child presently involved in any family or custody related legal proceedings?

Yes
No

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 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.

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.

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
Music & Expressive Arts Therapy
Verbal Psychotherapy
EMDR

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.

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.

Register for Counselling

Step 1 of 9

Guardianship

Financial Information

Terms of Service