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
Parent/Caregiver first and last name

First NameLast Name
Child first and last name

First NameLast Name
Full address, including postal code

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child's date of birth

MonthDayYear
Date
NOTE: Virtual is open for youth 12-21 at this time.

11. If no, list emergency contact information here-Full name, address with postal code and phone number
12. Relationship of emergency contact
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
14. Please list any mental health diagnosis, or diagnosis the therapist should be aware of.

15. Reason For Seeking Support
16. Have you seen a counselor, psychologist, psychiatrist or other mental health professional before?
17. If 'yes', tell us about the experience.

18. Tell us about your child's likes, dislikes etc.
19. Additional comments
The information you have provided above is truthful and you consent to PARSC contacting you.
Should be Empty: