Counselling Program - Intake Form

Sexual Assault Support Centre of Waterloo Region

Counselling Program - Intake Form
Please fill out all mandatory fields in order for us to know how to best serve you. Once you have submitted this form, you will be added to the appropriate waitlist. You will be contacted when a counsellor has a spot available for you. Once this form has been submitted, the Intake Worker will print off a copy for our records and delete the online version. This record will only be accessible to the Counselling team.

If you need to later update your information or need technical support in completing this form, please contact our Intake Worker directly at 519-571-0121 x 804 or at intake@sascwr.org
I am 16 years of age or older.*

YesNoOther
The counselling program at SASC is able to provide all services for those aged 16+ and Anti-Human Trafficking services for those aged 12+. If you are younger than these ages, please reach out to:

Sexual Abuse Treatment Program at Family and Children’s Services

The Sexual Abuse Treatment Program is available free of charge to any child or youth in Waterloo Region under the age of 18. They are able to offer information, support and education to anyone in the community with questions about sexual abuse, concerning sexual behaviours and healthy sexuality. For more information, please call 519-576-0540 ext.3679 or email them at inquiries@facswaterloo.org
I understand that SASC cannot provide services to those who have sexually offended as an adult (16 and older).*

YesI would like resources for a survivor who offended as an adult.
We invite you to contact Community Justice Intiatives as they offer support groups for those who have experienced and caused sexual harm.

https://cjiwr.com/

Tel. 519-744-6549
Fax. 519-744-6502
I am located within the Region of Waterloo. (Includes cities of Kitchener, Waterloo, Cambridge and townships of Wellesley, Wilmot, and North Dumfries.*

YesNoOther
SASC's service area is within the Waterloo Region. If you are located outside the Region, please visit the Ontario Coalition of Rape Crisis Centres to see which supports are closest to you: OCRCC- Support Near You.

If you are not sure where to find support, please don't hesitate to email us at intake@sascwr.org and we will be happy to help!
Today's Date*

MonthDayYear
Date
Name*

First NameLast Name
Date of Birth*

MonthDayYear
What is your gender identity?*
Preferred Pronouns (He/Him, She/Her, They/Them, etc.)
Contact Information

Please note that at least one means of communication must be filled. We strongly encourage you to provide an email address.
Main Phone Number

Area CodePhone Number
Is it safe to leave a message?

YesNo
Is this number:

CanadianInternationalTexting/Calls AppOther
What type of number is this?*

Cell PhoneHome PhoneWork PhoneOther
Secondary Phone Number

Area CodePhone Number
Is it safe to leave a message?

YesNo
Is this number:

CanadianInternationalTexting/Calls AppOther
What type of number is this?

Cell PhoneHome PhoneWork PhoneOther
Email Address*
example@example.com
Is it safe to send an email from SASC?*

YesNo
Preferred Contact*

Phone callEmailOther
Who referred you to SASC? Please include the organization name or your relationship to the individual, if applicable.*
Have you ever received services from SASC in the past?*

YesNo
Can you give more details? When? With who? *
Are you a post-secondary student?*

YesNo
What school do you attend?*

Conestoga CollegeWilfrid Laurier UniversityUniversity of WaterlooOther
Preferred location of services*

KitchenerCambridge
Preferred location of services*

CambridgeKitchenerUniversity of WaterlooWilfrid Laurier University
Which Township do you live in?

CambridgeKitchenerWaterlooNorth DumfriesWellesleyWilmotWoolwichOther

What is your availability for scheduling counselling appointments? Please select all that apply. (Please note we may not be able to accommodate all requests).*

	Monday	Tuesday	Wednesday	Thursday	Friday
9:00am to 12:00pm
12:00pm to 2:00pm
2:00pm to 5:00pm

Are you accessing services as a survivor of sexual violence or someone supporting a survivor of sexual violence?*

As a survivor of sexual violenceAs a supporter of a survivor
Do you have private insurance (from a work benefits plan, for example) that has coverage for counselling sessions?

YesNoNot sureOther

Counselling Program - Intake Form (Supporter)
Have you received any other counselling in the past?*

YesNo
Tell us about your prior counselling experience*
What prompted you to access counselling with SASC at this time?*
Who are you here to support?*

ChildSpouse/PartnerFriendOther
Do you currently have any informal supports? (Family, friends, coworkers etc)

YesNo
What supports are you receiving?

Confidentiality
I understand that all services are confidential and that the release of any information regarding my involvement with the Sexual Assault Support Centre of Waterloo Region may occur only with my written consent. I also understand that that the exceptions to this are:

1. Unreported cases of suspected child abuse or neglect or incidents of children witnessing domestic violence. SASC and your counsellor are obligated to inform Family and Children Services. In this event, staff will make their best efforts to inform you prior to any reporting, and if possible you will be present at the time the call is made.

2. If client indicates that they are a danger to themselves or others, SASC and staff are obligated to inform the appropriate authorities. Every effort will be made to inform you that a report will be made, and if possible you will be present at the time the call is made.

3. Upon subpeona to testify in court at the direction of a judge. Every effort will be made to ensure that you are aware of any court ordered intervention or subpeona, and every effort will be made to maintain client confidentiality before providing information.

4. Consultation with the counselling team at the Sexual Assault Support Centre or with an external clinical supervisor. Every effort will be made to maintain client confidentiality.
Name*

First NameLast Name
Today's Date*

MonthDayYear
Date
I agree to these terms*

YesNo
You must select "Yes" to be added to the waitlist. If you select "No", your information will be sent to the Intake Worker who will contact you to further discuss the Confidentiality policy. Please note that you must agree to the terms of this policy before beginning services at the Sexual Assault Support Centre of Waterloo Region.
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Sexual Assault Support Centre of Waterloo Region