Veith House Counselling Screening

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Please complete this form so that we can know about your counselling needs. Please note that completing this form is not a guarantee that you will be contacted for counselling. By completing this form you will be added to the counselling waitlist and contacted by the counselling intern if support can be offered.

Important: you are not required to answer any of these questions and you can leave questions blank, but your responses may help the counselling intern decide if they can support you.

What is your full name? (First and last name)

What are your preferred pronouns? (Select all that apply)

He/him

She/her

They/them

I would prefer not to share

Other:

What is your phone number?

What is your email address?

Do you have a preference for how the counselling intern contacts you?

I prefer phone

I prefer email

Phone or email is fine

Clear selection

What type of appointment would you prefer?

In-person appointment at Veith House

Phone call appointment

Video online appointment (Zoom)

Clear selection

Have you received counselling in the past?

Yes, but not through Veith House

Yes, at Veith House

Other:

Why are you seeking therapy at this time?

What do you expect from therapy?

How do you cope with stress?

What are the goals that you would like to accomplish in therapy?

Submit

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