CCSS - New Client Form

CCSS

New Client Form

Please complete the following confidential intake form.

info@crescentcare.ca

289-579-9939

Full Name

First NameLast Name

Date of Birth

Date

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Can we text you?

Can we call you?

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Address

Relationship Status

Race/Ethnicity

What service are you seeking (Please check all that are relevant to you)

Reason for Session

Occupation

School/Employer

Counselling Mode Preference

Private Health Insurance

Insurer

Insurance Policy/Group #

Insurance Member ID / Certificate

How did you hear about our counselling service?

If you were referred, kindly provide the name of the person who referred you.

Additional Comments

Notice for Clients: Please note that counselling services at Crescent Community Support Services are provided in partnership with Tazkiyah Health and Wellness INC and ISNA Canada.

By submitting this form, I authorize Crescent Community Support Services, Tazkiyah Health and Wellness INC, ISNA Canada, and its associated health professionals to collect my personal and medical information as documented above. I acknowledge that my personal and medical information is confidential and will only be disclosed to third parties with my explicit permission or when required by law. For more information, click on link below and go to the tab "Limits to confidentiality"

https://www.crpo.ca/standard-3-1-confidentiality/