Section 2: Cultural & Identity Information

Do you identify as Indigenous?

Yes No Prefer Not To Say{"type":"checkbox","name":"__generic10","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please check at least one item.","options":"Yes\nNo\nPrefer Not To Say"}


If yes: First Nations Inuit Métis Other{"type":"checkbox","name":"__generic11","width":100,"value":"","size":"Normal","validation":"C1","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)

{"type":"text","name":"__generic13","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}


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

{"type":"text","name":"__generic14","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}

Section 3: Referral & Reason for Contact

How did you hear about this service?

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Reason for seeking support at this time

{"type":"textarea","name":"__generic16","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":""}

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

{"type":"text","name":"__generic21","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}


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

{"type":"text","name":"__generic23","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}


Significant relationships and supports
{"type":"text","name":"__generic24","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}

Employment / education status

{"type":"text","name":"__generic25","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}


Other sources of support

{"type":"text","name":"__generic26","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}

Section 7: Health & Previous Support Services

Overall physical health

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Medical conditions

{"type":"text","name":"__generic28","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}


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

{"type":"text","name":"__generic32","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}


Substance use (if applicable)

{"type":"text","name":"__generic33","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}


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

{"type":"textarea","name":"__generic36","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":""}


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

{"type":"text","name":"__generic39","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}


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

{"type":"text","name":"__generic40","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}

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

{"type":"text","name":"__generic41","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}

Section 11: Practitioner Notes (For Office Use Only)

Observations

{"type":"textarea","name":"__generic42","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}


Summary of concerns

{"type":"textarea","name":"__generic43","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}


Recommended next steps

{"type":"textarea","name":"__generic44","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}