2023 Counselling – Children (6-15 yrs) Online Intake & Pre Survey

2023 Counselling - Children (6-15yrs) Online Intake & Pre Survey

"*" indicates required fields

MM slash DD slash YYYY
Session Type
If Parent(s) have completed a Parent Only session please indicate the therapist name the parent(s) met with
FSCA Client information regarding COVID-19
Parent(s) have you completed an Adult/Parent Only Online Intake form
Parent(s) must meet with the therapist for a Parent(s) Only session - prior to booking a Parent/Child session.
Bio Parent*
Address
Other Bio Parent
Address
Childs Name (if age 6-15yrs) (16 yrs & older can complete an Adult Counselling Intake & Pre Survey)
Gender*

MM slash DD slash YYYY
Child Relationship to Bio Parent
Child Relationship to Other Bio Parent
Address - (please note which parents address is applicable or if child's address is different than either bio parent)
Please note if child(ren) have different address than Parent that completed the Parent Only session.
May we contact you after your sessions have ended for post evaluations?
Type of Counselling - Child*
Family Status*
Do you identify as*
Were you born in Canada?*
If no, length of time in Canada
Office Use Only
How did you find out about our family and/or crisis counselling (please choose from the list)*
Please choose applicable
Please choose all that apply to your child(rens) 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?
Parents - how will this child session fees be paid?*
For Parent/Child(ren) Session - Do you have a preference for appointment day or time?
The session day/time clients choose may not be the Actual booking day/time.

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
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