First Name * Surname * Gender * Male Female Transgender Other Birth Date * Primary Phone Number (With Area Code) * Phone Type * Home Mobile Work Secondary Phone Number (With Area Code) Phone Type Home Mobile Work Street Address * City * Postal Code Your Email * Referred by Use this section to enter details on individuals living with Client. Leave addresses and phone numbers blank if they are the same as the Client’s Details. Family Member Name (1) Relationship with Client and age* if under 18 Address (Street, City, Postal) Phone Number (With Area Code) Family Member Name (2) Relationship with Client and age* if under 18 Address (Street, City, Postal) Phone Number (With Area Code) Family Member Name (3) Relationship with Client and age* if under 18 Address (Street, City, Postal) Phone Number (With Area Code) Family Member Name (4) Relationship with Client and age* if under 18 Address (Street, City, Postal) Phone Number (With Area Code) Additional Family Members Statistical Information Geographic Location * Aldergrove Brookswood Fort Langley Langley City North Langley City South Milner - Murrayville Rural South Langley Walnut Grove Willoughby Family Structure * Single Mom Single Dad Married with Children Couple Single Grandparents Foster Parents Sibling Other Guardian History of Mental Issues * Yes No History of Trauma * Yes No History of Substance Abuse * Yes No Is there a CURRENT Substance Abuse Issue (Alcohol or Drugs)? * Yes No Please specify the CURRENT Substance(s) * Is the Ministry of Children and Family Development involved with your family in a protection capacity? * Yes No Presenting Issues/Reasons for Counselling Relevant Medical History (Hold Ctrl to select multiple) History of Depression History of Anxiety Medication for Depressions/Anxiety Physical Health Issues Previous Direct Service/Supports (Hold Ctrl to select multiple) Group Therapy Individual Therapy Family Support Treatment by Community Agency Faith-based Support Group Availability (Hold Ctrl to select multiple) Monday (9:00 am – 3:00 pm) Tuesday (9:00 am – 3:00 pm) Tuesday (4:00 pm – 7:00 pm) Wednesday (9:00 am – 3:00 pm) Wednesday (4:00 pm – 7:00 pm) Thursday (9:00 am – 3:00 pm) Thursday (4:00 pm – 7:00 pm) Friday (9:00 am – 3:00 pm)