Counselling Request Form

Exclusively for InnoviCares Members

Innovicares - Counselling Request Form - ENG

If you are experiencing a crisis situation or any other urgent matter, please contact the 24/7 Aspiria Clinical Response Centre at 1-877-234-5327 or go to the nearest hospital emergency room.

Please enter your innoviCares UCI below. *

What can we do for you? *

First name *

Last name *

Gender *

Email *

Phone *

Extension

City *

Province *

Postal Code *

Pre-registered / I have received counselling from Aspiria before *

Yes. My information is on file.

No. This is my first time here.

Returning Visitors

Because your information is on file, you don't need to fill out the form again.

Pay for additional counselling sessions

Please tell us a little more about yourself:

Date of Birth *

Marital Status *

Please provide a brief description of the issue(s) for which you are seeking support: *

Have you ever received any support or treatment in the past? If so, briefly explain: *

Are you currently experiencing any thoughts of hurting yourself or anyone else, or are you experiencing any violence or abuse? If so, please explain: *

Do you have any concerns related to alcohol or drugs? If yes, please explain: *

In the past two weeks have you been feeling down or depressed?

Yes

In the past two weeks have you been feeling anxious?

Yes

May we contact you via your listed email address or phone number and leave a message?

Yes

Payment Information

The cost for a single counselling session is $120 plus HST. After you click "Submit Form" you will be directed to PayPal where you can pay via credit card or PayPal. A PayPal account is not required.

When done, click the "Return to ..." link on PayPal for next steps.

Quantity

Cost

Sales Tax

TOTAL

Consent *

Yes

By clicking on this box, I am providing my expressed consent to receive electronic communications including emails about new services and promotions from HumanaCare. I understand I may withdraw my consent at any time by emailing HumanaCare.

Please fill out the form to the left (all fields required)