CCO Intake Questionnaire Name* First Last Age Range Teen Skills & Support Group 12-14 Teen Skills & Support Group 15-17 16-17 18-24 25-34 35-44 45-54 55-64 65 or Above Prefer Not to AnswerNames of anyone to be included in the counselling sessionsIf there are any minors, please indicate their ages as well.Are you requesting individual or couples counselling? Family sessions are unavailable at this time.*Please choose oneIndividual (age 16+ only)CoupleTeens Skills & Support GroupPlease indicate your awareness that our current waitlist is approximately 3 months long for clients with daytime availability and up to 6 months for clients whose schedules can only accommodate evening or weekend sessions.*Please choose oneYes. I understand.I am applying for the Teen Skills & Support GroupWhat is the main reason you are seeking counselling? (Please be as specific as possible so that we can assign you to a therapist who will best be suited to help you with the issue.)*Have you had previous counselling with our organization?*Please choose oneYesNoWhich therapist did you see?*Please choose oneAlexiaAmyBrandiBenChrisHeatherJenniferJoanneLindsayLoriMargieSaraOtherNot listedHow did you hear about Christian Counselling Ottawa?* Church A Friend Radio Advertising Web Search OtherAre you interested in having prayer and/or Scripture as part of your counselling sessions?* Yes NoDo you attend a church? If so, which one?Fee CalculationOur fees are calculated based on the following information:What is your gross household income?*Please choose one$30,000 or under$30,000 to $50,000$50,000 to $80,000$80,000 to $110,000$110,000 to $150,000$150,000 +How many people are living off that income?*Please choose a number12345678910 or moreInsurance benefits coverage*Please choose oneYes. My benefits cover psychotherapy.I don't have insurance benefits.I want to use my EAP (Employee Assistance Program)I don't knowIf you are unsure about whether your insurance includes our services, please contact your employer or benefits provider. PLEASE NOTE: We do not have a supervising psychologist with our agency at this time. More information about insurance coverage is available on request. PLEASE NOTE: In order to determine whether your private/work EAP requires a referral from the employee's program, you must contact your EAP representative to determine eligibility and to receive a referral.AvailabilityPlease indicate your availability for counselling sessions. Scheduling flexibility will impact your waiting time. There is a strong demand for evening appointments. Waiting times for these sessions can be up to 6 months.* Monday - Morning Monday - Afternoon Monday - Evening Tuesday - Morning Tuesday - Afternoon Tuesday - Evening Wednesday - Morning Wednesday - Afternoon Wednesday - Evening Thursday - Morning Thursday - Afternoon Thursday - Evening Friday - Morning Friday - AfternoonMornings 9am-12pm | Afternoons 12pm-5pm | Evenings 5pm-8pmPlease identify your preferred method of counselling services. (PLEASE NOTE: While every effort is made to accommodate your preferences, they can not be guaranteed.*Main Office - 63 Glencoe St. (Hunt Club & Greenbank)Via Secure Video platformContact InformationAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country The intake team will contact you as soon as possible. Please provide us with the following contact information:Primary Phone Number*Phone TypePhone TypeCell PhoneHome PhoneWork PhoneSecondary Phone NumberPhone TypePhone TypeCell PhoneHome PhoneWork PhoneWhen is the best time for us to contact you?* Any time Morning Afternoon Evening 9am-5pm Are there any confidentiality concerns with leaving a message at either of those numbers?* No concerns Only leave message with name and number No messages Email Address* We do not sell or distribute email addresses and you will not be added to any email lists.Email Addresses of any other people attending sessions We do not sell or distribute email addresses and you will not be added to any email lists.Please let us know your preferred method of contact*Please selectEmailPhoneAny concerns or extra notes?Would you Like to receive our newsletter and other information from CCO?*YesNoPlease Note: By clicking 'YES', you are giving consent to receive our monthly newsletter and other special communications from Christian Counselling Ottawa. We do not share our email lists with any other organization.Δ
