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Mental Health Intake

The information collected in this form is legally protected and will remain confidential.

Please take your time to answer the questions to the best of your ability / comfort level.

First name*

Last name*

Date of birth*

Year

Month

Day

Parent / Guardian Name (if the primary client is a minor)

Address*

Email*

Phone*

Is it ok to leave a message at this number?*

Yes

Regarding your connection to the Canadian Armed Forces (CAF) are you*

Regular Force

Reserve Force

Veteran

Spouse / Partner

Child (6 to 12)

Youth (13 to 19)

Parent / Family of CAF Member

Other

Relationship status

Single (never married)

Married

Common Law

Divorced

Other

Please list any children, their age(s), and whether they live in your home.

Emergency contact name*

Relationship to your emergency contact (parent, spouse, friend, etc.)*

Emergency contact phone number*

Are you currently employed?

Yes, full time

Yes, part time

Yes, casual

Seasonal

Other

What do you do for work?

Regarding appointment times, are there days or times that work best with your schedule?

Please describe your reason(s) for wanting mental health support.*

Have you accessed mental heath supports before? If so, for what purpose / goals?

Have you been provided any formal mental health or medical diagnoses? If so, please elaborate to the extent you feel comfortable.

Are you taking any medications or supplements? If so, please provide the name, dose, and reason for taking.

Are there any other resources or supports you would like to be connected to?

Over the past 12 months, have you experienced or struggled with any of the following:

Suicidal thoughts

Suicide attempts

Self harm

Substance misuse / abuse

Hospitalization

Domestic / family violence

Is there anything else you would like us to know?

Initials*

I declare that the info I have provided is accurate and complete to the best of my knowledge

Comox Military Family Resource Centre

Centre de Ressource pour les familles de Militaire de Comox

Street Address | Adresse: 1575 Military Row, Comox, BC

Mailing Address | Adresse postale: PO Box 310, Lazo BC, Canada, V0R 2K0

Email: info@comoxmfrc.ca

Phone | Téléphone: (250) 339-8290 / 1-888-246-0222

Hours | Heures d'ouverture: Monday - Friday | 8:00am - 4:00PM

First name | Prénom*

Last name | nom de famille*

Email | courriel*

Message

Nous suivres

Fill out your Privacy and Confidentiality Consent Form
Remplissez votre formulaire de consentement à la confidentialité et à la protection des données personnelles.

Here | Ici

Mental Health Intake

Fill out your Privacy and Confidentiality Consent Form Remplissez votre formulaire de consentement à la confidentialité et à la protection des données personnelles.

Fill out your Privacy and Confidentiality Consent Form
Remplissez votre formulaire de consentement à la confidentialité et à la protection des données personnelles.