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aclestra centre
  • Our Practice
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    • Counselling modalities
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    • Counselling
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      • ADHD Group for Parents
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      • Concussion Support Group
    • Resources
  • Contact us
    • About Us
aclestra centre
  • Our Practice
    • Areas of practice
    • Counselling modalities
    • Fees & Forms
  • Services
    • Counselling
    • ADHD
      • ADHD Group for Parents
    • Concussion
      • Concussion Support Group
    • Resources
  • Contact us
    • About Us

Counselling Intake Form


Client contact info

*Legal name & what you go by

Emergency contact

What is going on for you?

Areas of concern

*Check all that apply

Personal Info

Therapy goals

I understand that the information I have provided is for therapeutic purposes only and that I am providing it voluntarily. I understand that the data is relayed to my counsellor at the Aclestra Centre and will not be shared with anyone else without my expressed consent.

Have a question?

We would like to help, but we can't if we don't know what you are thinking. 

So tell us - how can we help?

Contact us
Convenient scheduling

Online or in-person, daytime, evenings or weekends, in an office or take it outside.

What works for you?

Book an appointment
Learn more
ADHD
Concussion
Counselling
Resources
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