LCSS Client Intake Form - Parent Outreach

First Name *

Surname *

Gender *

Birth Date *

Primary Phone Number (With Area Code) *

Phone Type *

Secondary Phone Number (With Area Code)

Phone Type

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 *

Family Structure *

History of Mental Issues *

History of Trauma *

History of Substance Abuse *

Is there a CURRENT Substance Abuse Issue (Alcohol or Drugs)? *

Please specify the CURRENT Substance(s) *

Is the Ministry of Children and Family Development involved with your family in a protection capacity? *

Presenting Issues/Reasons for Counselling

Relevant Medical History (Hold Ctrl to select multiple)

Previous Direct Service/Supports (Hold Ctrl to select multiple)

Availability (Hold Ctrl to select multiple)

ADDRESS	Langley Community Services Society 5339 207 Street Langley, BC V3A 2E6
EMAIL	info@lcss.ca
PHONE	604 534 7921
FAX	604 534 3110