Couples Form

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

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

Our same day call-in clinic is for a single telephone session appointment today. Make sure you are in a comfortable and private area for your appointment. If you are not ready or able to speak to someone today, please register on a day you are available.

You also have the option of coming IN PERSON for a face to face session on Tuesdays and Thursdays between 1 and 7 pm. If you come in person – registration here is not required.

We will explore different ideas to help you with whatever is on your mind. Our approach focuses on solutions and the strengths you and/or your family possess. Single sessions have helped many individuals and families and we hope that you have a similar experience.

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

    Demographic Information

    You are registering for a couples session. Please enter your partner's information:

    Please continue entering your information:

    YesNo

    YesNo

    YesNo

    YesNo

    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.