Child Intake Form

Child's Name
Child's Gender
Does Your Child Have Any Siblings?
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.

Has your child had previous or current counselling?

Please explain

Has your child experienced any of the following?
Is there a police file open?
Are there charges active or pending?
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.

Sources of Family Income
Housing Situation of Family
Marital Status of Parents

(select all that apply)

Ethnic Culture

This question refers to the ethnic or cultural origins of a person’s ancestry, who we identify as, or what environment we are from.

Religious Culture

This question refers to how your child has been raised, based on the moral/social principles we use to govern our lives, and how we view the world.

My primary reason for counselling
Have you ever received a professional diagnosis and/or treatment for a mental health condition?
How would you score your current level of distress?

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