Adult Mental Health Intake Form

Adult Mental Health Intake Form

(Adult refers to those aged 19+)

Please fill out the form to the best of your ability.

If you do not know or do not feel comfortable filling out the information below, that is alright. The more information you can give, the better it will help REACH determine a support plan for you. If this referral is for yourself, you do not need to fill out the Referee Information. If you are filling this form out for a person you are concerned for and who has given consent to seek more information or support, please fill out the Referee Information

  • MM slash DD slash YYYY
  • Inquirer Information:

    (If you are filling this form on behalf of someone)
  • Information of Individual requiring mental health support:

  • phone, email, social media
  • Reason for concern or for inquiry for mental health services:

    (e.g., stress, PTSD, loss, anxiety, illness, COVID-19 impacts, relational issues, etc.)
    (check all that apply, this helps us identify the most suitable Service Provider available to support you).

    Mental Health Navigators include: - Family/Relational Counselling Support - Conflict and Mediation Counselling Support - Addictions Counselling Support - Grief and Loss Counselling Support - Situational Emotional Distress Support - Suicide-related Mental Health Support
  • Please provide any additional information on whom you are willing to receive support from.
  • Known Diagnosis / Medical Conditions / Areas of Challenge

  • Known support systems / Treatment or existing services in place

    check all that apply
    If a category is close/similar to your experience, please check and make a note in the comment below if you feel comfortable.
  • Please feel free to write any other, or extended, information here that you believe will better help explain.