Yukon Self-Intake Screening Web Form

What is your full name? If you are seeking couple's or family counselling, please include first and last name of all individuals.

Please confirm you are a member of the Government of Yukon

*You must be a member/household dependent of Government of Yukon to use this service.

Which Government of Yukon department or organization are you part of?

Please specify your department or organization.

Are you the Employee/Member or a Dependent/Family Member?

Other

What age range do you fall into? (If counselling is being requested for a child, please use the child's age, if counselling is being requested for a couple or family, please select all appropriate age ranges.)

What is your date of birth? (If counselling is being requested for a child, please use the child's date of birth. If couples or family counselling is being requested, please use one date of birth.)

Date

What is your full address

Street Address

Street Address Line 2

CityProvince

Postal Code

Phone Number:

Email Address:

Are you comfortable with messages being left by phone or email?

Other

Please indicate your gender identity:

Are you seeking legal, financial, or nutritional consultation?

Which area of legal consultation are you looking for?

(e.g., family law, real-estate law, criminal law, will contracts, etc.)

Which area of financial consultation are you looking for?

(e.g., budgeting, investments, tax planning, retirement, debt management, etc.)

Which area of nutritional consultation are you looking for?

(e.g., weight loss, Healthy Eating, dietary restrictions, Medical conditions, etc.)

Are you seeking a referral for counselling?

Please provide a reason for seeking support (main presenting issue, e.g., anxiety, depression, etc.)

Is it a single incident or cumulative

Are you experiencing any thoughts of wanting to harm yourself or others?

Yes (Please list any emergency contacts you are comfortable contacting in the case of any imminent danger to yourself or others. If you have a plan of intent please call 911)

Are you concerned about an abusive relationship you may be involved in?

Yes (Please explain. If you feel like you are in imminent danger please call 911)

Are you concerned regarding children or vulnerable adults in need of protection?

Yes (Please explain, including if any authorities have been involved)

Have you had any past treatment for mental health related issues?

Yes (Explain)

Do you work in a safety-sensitive position (e.g., operating forklift, machinery, vehicle)?

Yes (Explain)

Are you experiencing any alcohol or drug use issues?

Yes (Please include a brief description)

What substance(s) are being used and briefly describe the concern?

Frequency of use: Average number of days per week?

Average amount used per day?

Date of last use

Date

Any withdrawal symptoms (irritability, shakiness, difficulties thinking, hallucinations)?

Yes (explain)

Any past treatment for alcohol or drug use?

Yes (explain)

Have you engaged in counselling through MembersHealth Inc. in the past?

Yes (Would you like to be referred to the same therapist as before?)

What is your preferred mode of counselling? (Please select at least 2 options)

What is your preferred availability for counselling appointments? Please select all that apply.

Do you have a specific therapist you would like to work with?

If requested, we may contact the therapist about participating in the program. We cannot guarantee their participation or availability.

Therapist's First Name

First NameLast Name

Clinic or Organization

Optional

Therapist's email address

Please enter a valid email address

Therapist's phone number

OptionalFormat: (000) 000-0000.

Do you have any therapist preferences?

What is your primary language?

How did you hear about us?

Please note that you will be contacted within 2-3 business days by a MembersHealth Clinical Team Member or a therapist for booking. Should you need any further information or should you later need in-the-moment support, please call 1-800-484-0152 and you will be connected with the appropriate contact.

For any managerial requests, including those involving confidential leadership support, please reach out to your account manager to request access.

All personal information you provide through this form, including within 'Health, Wellness & Beyond,' is kept strictly confidential and will never be shared with your employer under any circumstances.