Counselling Intake Form

SASC's Counseling Program is designed for survivors of sexual violence aged 16 and above and their supporters.

Survivors under the age of 16 and those supporting them can access free counselling through the Sexual Abuse Treatment Program (link: https://www.facswaterloo.org/helpingfamilies/sexual-abuse-treatment-services).

Please note that we do not offer services for those who have caused sexual harm as adults. However, services are available through Community Justice Initiatives (link: https://cjiwr.com).

If you have any questions, please feel free to contact us via email at intake@sascwr.org or call us at 519-571-0121 ext. 804. We are here for you!

I am a...

survivor of sexual violence.supporter of a survivor of sexual violence.Other

First Name:

Last Name:

What month and year were you born in?

What community do you live in? (If you live outside of Waterloo Region, please visit: www.ocrcc.ca/)

Kitchener or WaterlooCambridge or North DumfriesWoolwich, Wellesley, or WilmotOther

Are you a student at:

University of WaterlooWilfrid Laurier UniversityConestoga College

Please provide an email address that is safe for us to send an email to.

Please provide a phone number that is safe for us to call.

Is it safe to leave a message at the above phone number?

YesNo

Can we send a text/SMS message to this phone number?

YesNo

If you would like to receive our client newsletter, please add your email address here:

example@example.com