University/College ISNA Cares

New Client Form

Please complete the following confidential form, if you are a post secondary student.

Contact Us:

Email: info@isnacares.ca

Phone: 647 370 7616
Are you a University/College Student?*

YesNo
Please select your University/College*

University of TorontoWaterloo UniversityOther
Student Number*
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Sex*

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
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-Martial)Couples Support (Marital)Family Mediation
Reason for Session*

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

In-PersonVirtual
Counselling Services Coverage

University students may be eligible for health insurance that covers mental health services, which can be used to pay for counselling sessions (if you're unsure, check with your insurance provider). If you don’t have this insurance or insurance coverage by a parent/guardian, ISNA Canada is committed to ensuring mental health support remains accessible for all. You may be eligible for subsidized counselling in-person or virtually. Please reach out at info@isnacares.ca for more information.

Notice for Insured Clients: Please note that our Insured Clients will be billed through Tazkiyah Health and Wellness INC.
Do you have University Health Insurance or Private Health Insurance?*

YesNoUnsure
Insurer
Insurance Policy/Group Number
Insurance Member ID / Certificate
How did you hear about our counselling service?*

ISNA Canada (ICC), (Jami), and (ICYK)CCSSOnline SearchSocial MediaReferred by Friend/FamilyReferred by Imam/DoctorOther (Please Specify)
If you were referred, kindly provide the name of the person who referred you.
Additional Comments
By submitting this form, I authorize ISNA Canada, Tazkiyah Health and Wellness INC, 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/
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