Intake Form Please share some info about yourself and your current needs. We will reach out to schedule an appointment as soon as possible! Name * First Name Last Name Pronouns Email * Phone (###) ### #### Date of Birth * MM DD YYYY Indigenous Description * First Nations Status First Nations Non-status Métis Inuit Other If "other" please specify Personal Health Number * Family Doctor's name & phone number * Are you currently taking medication? If yes, please list them. Emergency Contact Name * First Name Last Name Emergency Contact Phone Number * (###) ### #### Are you using drugs or alcohol? If yes, what types of substances: * Have you been diagnosed with psychological disorders (i.e. depression, anxiety, bipolar, schizophrenia, PTSD, etc. that required professional counselling? * Yes No Have you ever been hospitalized for psychological reason? * Yes No If yes, please elaborate. please tell us where, when, and for how long. Are you currently having suicidal ideation? If yes, do you have a plan? Please use the below blank space to discuss more about the wellness issues you are facing (Optional). *Note* We will complete a safety plan with you if you are experiencing suicidal ideation Did you, or anyone in your family, attend Residential School? * From the list below, please check the top four issues you would like support with. * Violence Grief Abuse Abandonement Shame Alcohol Drugs Gambling Sexual Addiction Life Skills Emotional Support Cultural Support Social Activities Aftercare Planning Other If other, please share anything we have missed. Thank you for reaching out! We honour your courage to seek support and will get back to you as soon as we can. Take care.
