Step 1 of 5 20% Today's Date: 01/15/2026Client #1 Info All fields marked with an * are mandatory.Name* First Name Last Name Address* Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Primary Phone*Alternate PhoneEmail* Enter Email Confirm Email OK to leave message? Select All Primary Alternate Email Birthdate* MM slash DD slash YYYY Gender* Male Female Non-Binary Other Prefer not to say Emergency Contact PersonPrimary PhoneAlternate PhoneEmergency Contact requestedCheck box if you cannot provide an emergency contact Cannot provide Client #2 Info Please complete only if this is a couple or family service request. If not, scroll down and click 'Next" to skip to the next section. Client #2 Name First Name Last Name Address Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Primary PhoneAlternate PhoneEmail Enter Email Confirm Email OK to leave message? Select All Primary Alternate Email Birthdate MM slash DD slash YYYY Gender Male Female Non-Binary Other Prefer not to say ServicesType of Service Individual Couple Family Group Referral Source Do you have fears for your safety or another family member?* Yes No Unsure Has there been any abuse (i.e verbal, emotional, financial), violence or threats of violence in your family/household?* Yes No Unsure Any Police and/or Court involvement or Outstanding Charges?* Yes No Unsure Do you have any concerns regarding your substance use?* Yes No Unsure Do you have any concerns regarding your family's substance use?* Yes No Unsure Comments & Presenting ProblemsCheck all that apply Anxiety Depression Trauma Abuse Grief / Loss Problems with Relationships Problems with Substance Abuse Separation / Divorce Financial Stress Parenting Other (describe in the comments section below) CommentsDo you require accommodations for accessibility?If you answer "Yes", this will be discussed during your Intake phone call. Yes No Special Request (i.e. language, location)Interpreter/ Intervener required? Yes No You answered 'Yes' to Interpreter/ Intervener required. Please specify language here.Times Available: Select All Mornings Afternoons Evenings Saturday If you would you like to receive appointment reminders, please indicate preference Via Email Via SMS Text Consent: Pressing submit will forward this information to the intake department. You will be contacted by intake to complete the next steps.* I agree to the privacy policy.
