Referral Counselling Form

Date of Intake

First Name:

Last Name:

Gender:

Male

Female

Trans-female to male

Trans-male to female

Intersex

Prefer not to answer

Do not know

Date of Birth:

Address

City:

Postal Code

Cell Phone:

Work Phone:

Email:

Permission to contact or leave a message:

Yes

No

Safe to leave a voicemail:

Yes

No

How did you hear about us?

Please write which other source

Marital Status

Children:

Yes

No

Age(s) of Children

Immigration Status

Temporary Resident

Refugee Claimant

Convention Refugee

Government-Assisted Refugees Program (GAR)

Permanent Resident

Canadian Citizen

Mental Health Diagnosis: (Yes or No), If yes, specify

Addictions Problems: (Yes or No), If yes, specify

Client's Spoken Languages:

Client's preferred language of service:

Level of Urgency

Level of Urgency

Any Safety Concerns (please specify):

What is your preference for the counsellor's gender?

Female counsellor

Male counsellor

No preference

Referred by: Solinas Elgamal

Referred by: Solinas Elgamal

Reason for Referral (A brief description of the issue(s) you would like to address at counselling):

Free Text

Disclaimer:

The counsellors we work with cannot provide crisis nor emergency services. They CANNOT support clients with active psychosis. Please call 911 for crisis or emergency.

"I understood and agree to this disclaimer"

Signature: First and Last Name

Date:

MIAG Centre for Diverse Women & Families

Referral Counselling Form

Contact us

3034 Palstan Rd. Suite M3

Mississauga, ON, L4Y 2Z6