Harambee Program-Therapy Intake Form
  • Harambee Program-Therapy Intake Form

  • Generously funded by The County of Simcoe. Parents Against Racism Simcoe County is excited to be able to offer this support to the community. If you need help with this form or have any questions, please email harambee@parsc.ca or call 705- 623-9791.

  • * Indicates required question
  • Child's date of birth*
     - -
  • NOTE: Virtual is open for youth 12-21 at this time.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • 9. How does the child identify?*
  • 10. Emergency contact information, is it the same as above?*
  • 13. PARSC offers individual counselling. List your preference and we will try our best to accommodate the request. Please keep in mind that there are a limited number of slots for each service. You may pick both options.
    Check all that apply.
  • Individual Therapy Preference
  • 16. Have you seen a counselor, psychologist, psychiatrist or other mental health professional before?
  •  
  • Should be Empty: