ISNA Cares - New Client Form

New Client Form

Please complete the following confidential form.

Contact Us:

Email: info@isnacares.ca

Phone: 647 370 7616
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Can we text you?*

YesNo
Can we call you?*

YesNo
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Address
Relationship Status*

SingleMarriedSeparatedDivorcedWidowedOther
Race/Ethnicity*

Middle Eastern/North AfricanSouth AsianWhite/CaucasianBlack/African AmericanHispanic/LatinoAsianNative AmericanMultiracialOther (Please specify)
What service are you seeking (Please check all that are relevant to you)*

Islamic SupportMental Health SupportCouples Support (Pre-Marital)Couples Support (Marital)Family Mediation
Reason for Session*

Depression / Anxiety / StressGrief / LossRelationship IssuesDomestic AbuseAnger ManagementAddictionLegal / Housing / Financial AidSuicidal IdeationOther
Occupation*
School/Employer*
Counselling Mode Preference*

In-PersonVirtual
Are you a OPS Employee or a family member of a OPS Employee?*

YesNo
UCIN Number
ISNA Canada has an agreement to provide EAP Counselling to OPS Employees and their families, in order to receive your UCIN, please call (1-888-212-8727) or go to www.opsinclusivecounselling.ca
Do you have Private Insurance?*

YesNo
Insurer*
Insurance Policy/Group Number*
Insurance Member ID / Certificate*
Payment*

I need ISNA Canada to fully subsidize my session.I would like to make a partial payment.I would like to make a full payment for my session.
How did you hear about our counselling service?*

ISNA Canada (ICC), (Jami), and (ICYK)CCSSOnline SearchSocial MediaReferred by Friend/FamilyReferred by Imam/DoctorFoodbankOther (Please Specify)
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 ISNA Canada are provided in partnership with Tazkiyah Health and Wellness INC and Crescent Community Support Services.

By submitting this form, I authorize ISNA Canada, Tazkiyah Health and Wellness INC, Crescent Community Support Services 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/
Should be Empty: