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Test forms

Not accessible to anyone without the link. This is to test the registration form with the added Race / Ethnicity element.

Register for Counselling - Feb 2023

Completed by Individual Seeking Service

Step 1 of 8

12%

Questions followed by an * are required
Who is this application for?*
- This is for myself
- This is for a child in my care
Would you prefer remote or in-person sessions*
- I am available to have a video session (this may require prepayment by credit card or e-transfer)
- I am available to have a phone session (this may require prepayment by credit card or e-transfer)
- I am only available in person
Guardianship
If the participant 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.
Guardianship & Custody*
If you are creating this application for a child in your care, please indicate the present guardianship & custody arrangements.
- 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.
Relationship to the child*
If you are creating this application for a child in your care, please indicate your relationship to the child
- Biological Parent
- Foster Parent
- Adoptive 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
Are you 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: Aulneau Renewal Centre employees cannot become involved in any active court proceedings on a clients behalf.
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.

Participant's Name*
First Last
Participant's Birthdate*
Gender*
Race/Ethnicity
Please check all categories that best identifies the person for whom counselling services are requested.
- Black (African, African Canadian, Afro-Caribbean descent)
- Caucasian (European descent)
- East Asian (Chinese, Japanese, Korean, Taiwanese descent)
- Indigenous (First Nations, Inuk/Inuit, Metis descent)
- Latin American (Hispanic or Latin American descent)
- Middle Eastern (Arab, Persian, West Asian descent {e.g., Afgan, Egyptian, Iranian, Kurdish, Lebanese, Turkish})
- South Asian (South Asian descent {e.g., Bangladeshi, Indian, Indo-Caribbean, Pakistani, Sri Lankan})
- Southeast Asian (Cambodian, Filipino, Indonesian, Thai, Vietnamese, or other Southeast Asian descent)
- Other
- Do not know
- Prefer not to answer
Personal Pronouns?
- she/her/hers
- he/him/his
- they/them/their
- no pronoun (please just use my name)
Participant's Primary Address*
Street Address Address Line 2 City Province Postal Code
Participant's Primary Phone Number*
Is it safe to leave phone a message?*
- Yes
- No
Participant's Email*
Consent To Correspond Via Email?*
- Yes
- No
Emergency Contact Person*
Emergency Contact Phone*
Emergency Contact Relationship?*

Where are you requesting services?*
- Winnipeg
- Steinbach
Are you open to services in Winnipeg?*
- Yes
- No
What type of services are you requesting?*
- Individual Child/Youth
- Individual Adult
- Dyadic Parent/Child
- Couples
- Family
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
DD slash MM slash YYYY
Your Relationship to the Child
Please indicate your relationship to the child/youth who will be attending therapy with you.
- Biological Parent
- Foster Parent
- Adoptive Parent
- Relative
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.
- she/her/hers
- he/him/his
- they/them/their
- no pronoun (please just use their name)
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
- Drama Therapy
- Music Therapy
- Verbal Psychotherapy
- EMDR
What type of Therapy are you requesting?*
- Music Therapy
- Verbal Psychotherapy
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.
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
- English
- French
- No preference
Have you accessed services at Aulneau Renewal Centre before?*
- Yes
- No
How did you hear about Aulneau Renewal Centre?*
- Family Doctor
- School
- CFS
- MATC
- Other Counselling Agency
- Friend
- Family Member
- Social Media
- Online Search
- Family Conciliation
- I am a returning client
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.

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.
Please select the topic(s) below that are concerns for you at this time.*
- 2SLGBTQQIA Concerns
- Abuse (Emotional, Mental, Physical, Sexual, Spiritual)
- Addiction
- Anger
- Anxiety/ Anxiety Disorders
- Childhood Trauma
- Chronic Pain
- Defiant Behaviour (ODD; Aggression)
- Depression/ Depressive Disorders
- Developmental Difficulties
- Emotion Regulation
- Gender Identity
- Grief, Bereavement & Loss
- Intimate Partner Violence
- Mood Disorders
- Parenting Skills/ Attachment Concerns
- Personality Disorders
- Relationship Conflict
- Schizophrenia/ Psychotic Disorders
- Self-Esteem
- Self-Injury
- Separation/ Divorce
- Sexuality/ Sexual Identity
- Sexual Violence/ Sexual Assault
- Sleep Disturbances
- Social Skills
- Spectrum Disorders
- Spirituality
- Stage of Life Issues
- Stress & Overwhelm
- Suicidal Ideation
- Trauma (PTSD; C-PTSD)
Are you currently having suicidal thoughts/ thoughts of harming yourself?*
- Yes
- No
Have you had suicidal thoughts/ thoughts of harming yourself in the past?*
- Yes
- No
Are you currently having thoughts of harming others?*
- Yes
- No
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.
Concern 1*
Concern 2
Concern 3
What do you hope will change as a result of coming for counselling?

What do you do when you feel stressed or overwhelmed?
Who do you turn to when you need support?
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?
Changes in Physical Health
Emotional Changes
Mental Health Changes
Spiritual Changes

Financial Information
Thank you for your application! The next step is for us to determine your rate for services and method of payment.
Do you have insurance or any other coverage* for counselling services?*
- Yes
- No
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 $120.00. - 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.
Terms of service*
- I have read and understood these terms
Will you be using your insurance or other coverage?*
- I will be using my insurance
- I will not be using my insurance
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 select your annual household income*
- $9,999 and Under
- $10,000 - $14,999
- $15,000 - $19,999
- $20,000 - $29,999
- $30,000 - $39,999
- $40,000 - $49,999
- $50,000 - $59,999
- $60,000 - $69,999
- $70,000 - $79,999
- $90,000 - $99,999
- $100,000 and Over
Please select the number of people living in the home.*
- I am alone
- One dependent and myself
- Two dependents and myself
- Three dependents and myself
- There are 5 or more of us
Please indicate your insurance provider(s).*
- Blue Cross
- Great West Life
- Green Shield
- Jordan's Principle
- Sunlife
- The Cooperators
Which professional designations are you covered for?*
- Registered Social Worker (MSW)
- Registered Psychotherapist
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
Terms of service*
- I acknowledge and confirm that I have read the 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
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Winnipeg Office:
228 Hamel Avenue Winnipeg, MB R2H 0K6
204-987-7090 - reception@aulneau.com

Steinbach Office:
345 Loewen Boulevard Steinbach, MB R5G 0C3
Appointments made through Winnipeg office.

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Aulneau Renewal Centre is located on original lands of Anishinaabe, Cree, Anisininew Nations, Dakota, and Dene peoples, and on the homeland of the Métis Nation. We respect the Treaties that were made on these territories, we acknowledge the harms and mistakes of the past, and we dedicate ourselves to move forward in partnership with Indigenous communities in a spirit of reconciliation and collaboration.

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