2022 FSCA Counselling Online Intake & Pre Survey

2022 Counselling - Child (6-15yrs) Online Intake & Pre Survey w/screening

"*" 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
Parents - how will this child session fees be paid?*
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*
Other Bio Parent
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 - if different than either 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?
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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