Adult Community Counselling Intake / Referral

If requiring an immediate response visit Lady Minto Hospital (M-F 8:00 AM – 4:00 PM) or call (250) 538-4849

After hours (4:30 – Midnight)  support is also available by calling Vancouver Island Crisis Line at 1 (888) 494-3888 

Call 911 in an emergency

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Referral Information

Referral Date *

Referred by *

• Self
• Other

If other, please provide your:

Name

Phone

Email

Relationship to Client

Agency

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Client Contact Information

Name *

First

Last

Preferred Pronouns

Date of Birth

Age

Primary Phone

Can we leave messages on this phone number

• Yes
• No

Email

Alternate Method of Contact

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Presenting Concerns

Reason for Referral / Counselling Goals

Section Divider

Please select all that apply: a more in-depth intake will be completed with the Counsellor.

Wellness Concerns

• Mental / Psychological
• Physical
• Emotional
• Spiritual
• Life Transitions

Suicide Risk

• Yes
• No

If Yes

• Low
• Medium
• High

Self Harm Risk

• Yes
• No

If Yes

• Low
• Medium
• High

Substance Use

• Current Use
• In Recovery

Please check all that apply

• Depression
• Phobias
• Anxiety
• General Stress
• Distorted Body Image
• Feeding / Eating Issues
• Sleeping Disturbances
• Chronic Pain
• Self Esteem Issues
• Trauma
• Post-Partum Depression
• Significant Loss / Grief
• Relationship Challenges
• Abuse / Violence
• Addictive Behaviour (Non-Substance Use)
• Court / Legal Involvement

Other not listed (Please Specify)

Accessibility Needs / Barriers

Supports / Other Service Providers Involved

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