Counselling Intake Form

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The following questions are being asked to help us evaluate and fund our programming. Answering the questions is completely voluntary, and the information shared with us will be kept confidential.

On what day will your counselling session take place? *

Click on the calendar icon to select a date

YYYY

At what time will your counselling session start? *

Enter the time and use the drop-down menu to select AM or PM

Time

How old are you? *

Please select one of the following options

18 years or younger

19-25 years old

26-30 years old

31-35 years old

36-40 years old

41-50 years old

51+ years old

Prefer not to say

How would you describe your gender? *

Please check all that apply

Cis woman/ girl

Cis man/ boy

Trans woman/ girl

Trans man/ boy

Non-binary or gender-queer

Prefer not to say

Other:

Required

How would you describe your race or ethnicity? *

Please check all that apply

Indigenous to Turtle Island (e.g First Nations, Inuit/Inuk, Metis)

East Asian (e.g China, Japan, S.Korea etc)

Southeast Asian (e.g Thailand, Vietnam, Philippines etc)

South Asian (e.g India, Pakistan, Bangladesh etc)

Black- Africa (e.g Somalia, Kenya etc)

Black- Caribbean (e.g Jamaica, Barbados etc)

Black- North America

Latin American (e.g Argentina, Chile, Ecuador etc)

Indian-Caribbean (e.g Guyana, Trinidad and Tobago etc)

Southwest Asian/ North African (S.W.A.N.A) (e.g Iran, Egypt, Afghanistan, Lebanon etc)

White- North America

White- Europe (e.g England, France, Italy, Poland, Russia etc)

Another Option

Prefer not to say

How did you find out about our counselling program? *

Please check all that apply

From a community organization

From school

From a friend or family member

From a doctor, nurse, or other healthcare provider

From a search engine like Google

From a social media platform like Facebook or Twitter

From a poster, pamphlet, or other form of advertising

Prefer not to say

Other:

Required

Is this your first counselling session with us? *

Please select one of the following options

Yes

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