Counselling Intake Form
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
MM
/
DD
/
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
How would you describe your gender? *
Please check all that apply
Required
How would you describe your race or ethnicity? *
Please check all that apply
How did you find out about our counselling program? *
Please check all that apply
Required
Is this your first counselling session with us? *
Please select one of the following options
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