Couples Form


Le formulaire en francais est ici.

This form is for couples seeking Walk-in counselling. Please note, each partner must submit a separate form.

For individual counselling, click here.

Please Note: Our Walk-in Clinic has now been changed to a “Call-in Clinic” in order to help control the spread of Covid-19.

Our Walk-in Call-in counselling service will offer you a single telephone session appointment to meet with a counsellor to talk about your concern(s). We will explore different ideas to help you with whatever has brought you here today. Our approach focuses on solutions and the strengths you and/or your family possess. We know that a single session has helped many individuals and families and we hope that you have a similar experience.

Our Call-in (Walk-in) Clinic hours are Tuesday and Thursday afternoons from 1pm to 7pm.

If you are in crisis, please call the crisis line at: 705-495-8198 or 1-800-352-1141.

What to expect from your visit today:

  1. You will be asked to answer some questions with the counsellor before your session begins.
  2. CCCNIP does not provide court letters or reports for clients of the Call-in Clinic.
  3. Everything you share is confidential.

The only exceptions are the following:

  • If your file is subpoenaed by a court of law
  • If a child or youth age 18 or under is being abused
  • If you are at risk of harming yourself or someone else
  • If you disclose that a person with a developmental disability is being abused or neglected

    I/We understand and consent to the above counselling and service conditions.

    Demographic Information

    Vous recherchez une consultation de couple. Veuillez saisir les informations de votre partenaire :

    Please continue entering your information:




    Risk Assessment Summary

    Addictions (alcohol, drugs, gambling)Intimate partner or family violenceSexual assaultDevelopmental disabilitiesFinancial problemsWork or interpersonal conflictRisk to self or other

    Intimate Justice Scale

    Please rate each statement on a scale of 1 to 5 (1 means “I do not agree at all” and 5 means “I strongly agree”).
    Your answers are confidential and will not be shared with your partner.