Organization Information

Organization or Agency*

Billing Address*

Street Address City Province Postal Code

Billing Phone Number

Worker/Advocate Name*

First Last

Worker/Advocate Phone Number*

Worker/Advocate Email*

Client Information

Type of Service Requested At This Time*

Individual Child/Youth
Individual Adult
Dyadic Caregiver/Child
Couples
Family
Parent Coaching
Dragonfly

Client Name*

First Last

Client Birthdate (Day, Month, Year)*

Address*

Street Address Address Line 2 City Province Postal Code

Client's Gender*

Partner's Name*

Partner's Birth Date*

Partner's Primary Phone Number*

Partner's Primary Email*

Is the child in care?*

Yes
No

Reason for original apprehension (if applicable)

How many placements has the child been in? (if applicable)

Years with current family (if applicable)

Current caregiver and child's relationship strength's & weaknesses (if applicable)

Difficult behaviour's appear at? (if applicable)

Caregiver Name(s)*

Caregiver's Relationship to Child/Youth Client*

Biological Parent
Foster Parent
Relative

Client/Caregiver Primary Phone Number*

Client/Caregiver Secondary Phone Number

Client/Caregiver Email*

Client's Primary Address*

Street Address City Province Postal Code

Reunifying Caregiver's Name*

First Last

Reunifying Caregiver's Birthdate*

Reunifying Caregiver's Address*

Street Address Address Line 2 City Province Postal Code

Reunifying Caregiver's Phone Number*

Reunifying Caregiver's Email

Does the child have a pre-existing relationship with the reunifying caregiver?*

Yes
No

What is the frequency of current in-person visits between child and reunifying caregiver? (How often per week)*

Please enter a number from 0 to 7.

Is there room to increase visits to 2 times a week, 2 hours per visit?*

Location Requested for Counselling Services*

Language Preference for Services*

English
French

Type of Counselling*

Play Therapy
Drama Therapy
Music Therapy
Verbal Psychotherapy
EMDR

Type of Counselling*

Play Therapy
Verbal Psychotherapy
EMDR

Is the client currently having thoughts of and/or actively harming themselves?*

Yes
No
Unknown

First Concern to be Addressed in Counselling*

Second Concern to be Addressed in Counselling*

Third Concern to be Addressed in Counselling*

Client's Strengths & Other Resources*

Desired Outcomes/Changes for Client (ie. Goals for Therapy)*

Diagnoses - Suspected or Confirmed

Any Additional Information?

Additional Documents (eg. Case Reports; Clinical Reports; Psych Assessments; School Assessments; Social History)

Drop files here or

Max. file size: 100 MB.

Accessibility

Please indicate any accessibility needs you have that we should be aware of when accessing services at our centre.

Terms of Service*

I acknowledge and confirm that I have read the Terms of Service.

CAPTCHA

Untitled

Contract Counselling Intake

Organization Information

Client Information