Request for Service

First Name:: *

Last Name:: *

Enter a preferred name if it is different from your legal name. :

Would you like us to use your preferred name instead of your legal name when contacting you?:

Yes

No

How do you identify your gender?: *

What pronouns do you prefer? (i.e. female, male, zie, other):

Enter your date of birth:: *

Enter the address where you are living. Entering this address does not mean we will contact you there.: *

City:: *

Postal Code:: *

Enter a telephone number where we can contact you:: *

When is the best time to contact you to book an initial appointment?: *

9am-12pm

12pm-3pm

3pm-6pm

6pm-8pm

Can we leave a message for you at this number? If you ask us to be discrete we will not state where we are calling from. : *

Yes

Yes, but be discrete

No

Email Address:

What is the best way for us to contact you?: *

Telephone

Email

Are you interested in: *

Individual Counselling

Family Counselling

Please tell us if you are interested in accessing individual or family counselling

If you are interested in Family Counselling::

Please list all family member's full names and date of birth for those who will be attending counselling.

Tell us a bit about what has brought you to seek our services? (i.e. What would you like support with?): *

Do you have thoughts of harming yourself or someone else?: *

Yes

No

Do you currently have thoughts of suicide/harming yourself or harming someone else?

If yes, can you explain?:

Please tell us more about your thoughts of harming yourself/someone else and how often they occur.

What is your use of drugs/alcohol?: *

Please tell us about your use of drugs/alcohol.

Do you engage in self injury? (i.e. cutting, burning, hitting, etc.): *

Yes

No

Are you currently taking any prescription medications?: *

Yes

No

If yes, what medications?:

Do you have any allergies or medical conditions we should be aware of?: *

Please tell us about any allergies and/or medical conditions we should know about when providing counselling. If you have none, type none.

Is there any pushing or shoving in your home or primary relationship (i.e. partner)?: *

Yes

No

Are you able to attend counselling at our main office (480 Charles St. East, Kitchener)? We are able to provide bus tickets. Occasionally we provide services to youth outside our main office. : *

Yes

No

Best time to book appointments?: *

9am-12pm

12pm-3pm

3pm-6pm

6pm-8pm

Anything else we should know?:

Please tell us anything else you think we should know about providing you with counselling.