Child Intake Form

Child's Name
Child's Gender
Parent One - Primary Contact

Please provide first and last name

Parent Gender
Parent Two

Please provide first and last name

Parent Gender
Primary Reason for Counselling
Best way to contact or leave message about appointments

Parent One - Primary Contact information will be used

Do you have insurance coverage?

Please indicate, as this impacts which counsellor you will be assigned to.

Do you have Custody Arrangements if Divorced or Separated?

Please note: We must have copies of the child custody arrangements before we can see your child.

Does Your Child Have Any Siblings?
My primary reason for counselling
How would you score your current level of distress?
Has your current distress included thoughts or action of suicide?
Has your current distress included thoughts or actions of self harm?

If you feel at risk right now, support is available 24/7 at:

  • Mental Health Distress Line 877.303.2642
  • Suicide Help Line 800.232.7288
Are there risk or time factors adding to the urgency of your counselling?
Do your counselling goals include a spiritual perspective?
Do your counselling goals include a cultural perspective?
Do you feel currently you have supportive relationships in your life?
Are there health conditions that may impact your counselling goals?
Have you ever received a professional diagnosis and/or treatment for a mental health condition?