Everything you share is confidential and used only to create a clear, supportive treatment plan tailored to you. Please answer each question honestly and to the best of your ability.

We appreciate your trust and look forward to supporting your growth and well-being.

Section 2: Cultural & Identity Information

Do you identify as Indigenous?

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If yes: First Nations Inuit Métis Other{"type":"checkbox","name":"__generic11","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"First Nations \nInuit\nMétis \nOther"}

Community / Nation / Territory

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Languages Spoken (e.g., English, Cree, French)

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Spiritual, cultural, or traditional practices to be respected in sessions

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Section 3: Referral & Reason for Contact

How did you hear about this service?

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Reason for seeking support at this time

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Section 4: Service Preferences

Preferred format of sessions: 

In Person Virtual Combination{"type":"checkbox","name":"__generic17","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"In Person\nVirtual\nCombination"}


Preferred time of day (Morning / Afternoon / Evening)

Morning Afternoon Evenings{"type":"checkbox","name":"__generic18","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Morning\nAfternoon\nEvenings"}


Type of service:

Family Couple Group{"type":"checkbox","name":"__generic19","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Family\nCouple\nGroup"}

Section 5: Presenting Concerns

Main concerns or issues to address

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Duration of these concerns

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Previous strategies or supports used

{"type":"textarea","name":"__generic22","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":""}

Section 6: Current Life Situation

Living arrangements

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Significant relationships and supports
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Employment / education status

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Other sources of support

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Section 7: Health & Previous Support Services

Overall physical health

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Medical conditions

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Medications or traditional medicines

{"type":"text","name":"__generic29","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}


First time meeting with a social worker/coach?

Yes No{"type":"checkbox","name":"__generic30","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Yes\nNo"}


Previous counselling or support services received

{"type":"textarea","name":"__generic31","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":""}


Reason for changing counsellors or services

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Substance use (if applicable)

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Sleep quality

{"type":"text","name":"__generic34","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}


Typical energy levels

{"type":"text","name":"__generic35","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}

Section 8: Personal Strengths & Coping

Strengths and qualities you value in yourself

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Coping methods that help during stressful times

{"type":"textarea","name":"__generic37","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":""}

Section 9: Goals for Service

Desired changes or outcomes

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Indicators of progress or improvement

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Would you like to use different tools of therapy other than counselling/coaching? (e.g., massage, light therapy, sound therapy)

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Section 10: Consent & Confidentiality

I understand that information shared will remain confidential except when required by law (e.g., risk of harm to self or others, child protection concerns, legal requirements).

Signature

{"type":"signature","name":"__signature","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please enter your signature.","height":150}


Date

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Section 11: Practitioner Notes (For Office Use Only)

Observations

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Summary of concerns

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Recommended next steps

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