Intake Form

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Your Name

First

Last

Date of Birth

Please complete the following so we can get in touch with you.

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Cell Phone Number

Please specific the type

Other Phone Number

Please specific the type

Is TFCC your Employee Assistance Provider? If yes, specify employeer.

What are your reasons for seeking counselling? (optional)

Please complete the information you are comfortable answering.

Gender (choose one)

Sex

Primary Language

Secondary Language

Ethnicity

Marital Status

Employment Status

Employer

Employment Status of Partner

Obligatory if the client is under the age of 18-years old

Their name

First

Last

Their date of birth

Their gender

Relationship with client

I.e. parent, guardian, etc

Address

If different from client

Their Cellphone Number

Their Email

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