Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Permission to send correspondance via mail? *

Yes

No

Phone

(###)

###

####

Permission to contact via phone and leave messages *

Yes

No

Permission to send emails *

Yes

No

Do you prefer your services in French? *

Yes

No

Are you connected/involved with other service providers: *

Please select all that apply

Not involved

CAS

Probation &Parole/Family Court/Criminal Court

Other

Are you taking any medication for your mental health? *

Yes

No

Risk Factors *

The following questions are asked to assess your current risks. Please check all that apply.

Financial concerns

Risk of harming self

Current thoughts of sucide

Thoughts/wants of hurting others

Unable to care for self

Problems with the law

Medical conditions affecting daily living or mental health

Current or potential loss of housing

Addictions affecting daily life or mental health

History of Abuse *

The following questions are asked to assess history or current experiences with abuse. Please check all that apply

Physical abuse

Sexual abuse

Financial abuse

Human trafficking

Verbal or Emotional abuse

No history or current experience with abuse

Activities of Daily Living *

The following questions are asked to assess how your mental health is affecting your quality of life. Please check all that apply.

Change in sleep (too much or too little)

Changes in appetite (eating too much or not enough)

Changes in personal hygiene (unmotivated to shower, brush teeth, etc)

Changes in social acitivities (lack of interest, isolation)

No Changes