2023 Counselling – Adult OR Parent(s) Only Intake & Pre Survey

2023 Counselling - Adult OR Parent(s) Only Intake & Pre Survey

"*" indicates required fields

MM slash DD slash YYYY
Counselling - Session Type
After booking - session type can be changed by: replying to your Appointment Confirmation and/or Reminder Text, Email or phone call OR contacting Counselling direct line 403-309-8221.
*Please note that a preference or referral cannot guarantee a session with the therapist noted - due to scheduling the preferred therapist may not be available.
FSCA Client current COVID-19 screening

MM slash DD slash YYYY
Ok to leave Voicemail on Cell Phone
**Please Note: clients with gmail.com, yahoo or hotmail email accounts - please check your Spam/Junk Folder for FSCA Counselling emails. Thank you
May we contact you after your sessions have ended for a post evaluation?*
Type of Counselling
Marital Status
Family Status
Are there any legal proceedings scheduled in relation to the issue noted above?*

FSCA Therapists do not get involved in legal issues - they may make referrals for this to other agencies.
Are there any files open with Central Alberta Child-Family?*

FSCA Therapists do not have a contract to work with this agency and may be able to make a referral.
Do you identify as:
Were you born in Canada?
Length of Time in Canada
Please answer the following Pre Survey questions as they assist agency program funders, thank you.
Did you require United Way subsidized session fee?*
This is for short term immediate intervention counselling.
How did you find out about our family and/or crisis counselling*

Please choose all that apply to your situation*
"I have an understanding of the situation that brought me here"*
"I feel good about my future"*
"I am able to effectively communicate in my meaningful relationships (children/spouse/partner/co-parent)*
Have you ever had previous counselling for this particular issue?*
If this Intake is for a Couples or Family Session - please note spouse/partners OR a family members name, thank you.
Do you have a preference for appointment day or time?
The session day/time clients choose may not be the Actual booking day/time.
Do you prefer initial contact by:
Emails to Gmail, Hotmail, Yahoo and Outlook may go to clients Email Junk Mail. We are able to text to both iPhone & Android.
Appointment Reminders
Session Fees
Will you be paying on your own OR with employment benefits?
If you are experiencing Financial Hardship - FSCA has United Way funded subsidized fee Insurance (Blue Cross, Great West, etc) - client pays fee & submits receipt for reimbursement EAP - fee billed to EAP - contact your employment HR for details
If paying with employment benefits insurance please check applicable
FSCA Therapist Credentials - please check the applicable credential accepted by your Insurance plan
Session Payment Type - Please Pay Session Fee on Date of Session

Contact Details

Main Office:

Family Services of Central Alberta
5409 - 50th Avenue
Red Deer, Alberta
T4N 4B7

Office Hours

Main Office:
8:30am – 4:30pm
Extended hours on Monday/Tuesday:
5:15pm – 8:00pm
Toll Free: 1-866-414-3722
Email us: fsca(at)fsca.ca

Park Plaza Intergenerational Centre

5214 - 47 Avenue, Red Deer
Visit by appointment only Phone: 403-967-0171

Parkland Mall Kinsmen Family Play Space

Hours of Operation:
Monday - Friday
9:30am – 3:00pm
Parkland Mall:  4747 - 67th Street, Red Deer