GET IN TOUCH

USING OUR INTAKE FORM

If you or someone your know is in danger, please call 911.

If you need to talk to someone right away and you cannot reach us or it is outside of our hours, we recommend you contact 211 right away.

If you would like to use it to request services, please complete our intake form below.

Your privacy is important to us. We will not use your personal information for any purpose other than responding to your inquiry.

Is this counselling for yourself or someone else?

Please check one.

Counselling type:

Please check one.

If this counselling is for someone else, please fill in the following fields.

Date

YYYY

Your name

First Name

Last Name

Best number to reach you:

(###)

###

####

Can we leave you a voice message?

Please check one.

Email address

We will send you a reminder of your appointment once we set it up. Please provide email or phone # you want us to use.

Is the client(s) aware of the referral?

Who is the appointment for?

Client Name(s)

First Name

Last Name

Client Preferred name

First Name

Last Name

Client Pronouns

Client Date of Birth

YYYY

Client Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Client Contact Number

(###)

###

####

Alternate number for client

(###)

###

####

Can we leave a voice message?

Client Email Address

Are you a client of Social Development?

Please check one.

What would you like to talk to a counsellor about?

Additional information

In order to connect you with the right counsellor, please give as much information as you are comfortable with. All information is completely confidential.

Do you have any preference for time of day for your appointment?

Please check one.

In most instances we can offer virtual counselling (except for younger children). Do you have a preference?

Please check one.

Do you have EAP coverage through your employer?

Please check one.

If yes, who is your employer?

How would you like to receive appointment reminders?

Please check one.

Are the concerns you are reaching out about so significant you are considering suicide?

If you are in crisis please go to your local ER or here are some additional phone numbers to consider calling: - Mobile Crisis Saint John 1-888-811-3664 (Hours: 11am-11pm and 24-hour telephone response) - Chimo Crisis Line: 1-800-667-5005 www.chimohelpline.ca/contact.html - Crisis Services Canada-Suicide Prevention and Support 1-833-456-4566

To help reduce spam, we have added Google reCAPTCHA to our forms. Google reCAPTCHA prompts visitors to check a box to prove that they’re not a robot before they submit their information. In some cases, they’re also prompted to complete another task, like identify a string of letters or select specific images. This method makes it difficult for spambots to complete form submissions using strings of code to autofill and submit the form. This site uses reCAPTCHA V2.

Instead of having the form information stored in an online database, our form information is sent directly to Family Plus’ Intake Coordinator as an email. This means your information arrives on a secure computer, where it is reviewed and stored according to our normal security protocols for personal information.

Address

621 Fairville Blvd. Unit 1D4
Saint John, NB E2M 4X5

Email
info@familyplus.ca

Phone
506-634-8295
Toll Free 800-360-3327