CariCope Wellness Intake Form
Please fill out our confidential intake form as accurately as possible. We carefully screen our clients to determine if our services are suited to their needs. This means you won't be billed until you are matched with a mental health coach. Note on our matching system: for Caribbean-based clients, we try to match you with coaches who are from an island outside of yours for an added sense of privacy.
Name *
Have you received mental health services from us in the past?
Clear selection
Please select the response that applies to you. *
Date of Birth *
MM
/
DD
/
YYYY
Gender
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Email *
Phone number *
Primary Language
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Voucher Number
Sister2Stister Program Members only
How would you like us to contact you to set your first appointment? *
Country of Birth *
Type in your country if not listed
Are you currently located in your country of birth? *
Employment Status
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Relationship Status
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Are you currently receiving mental health counseling/therapy? *
Have you received a mental health diagnosis in the past? *
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