BeMorr Client Intake Form

If you are in Immediate Crisis contact your local distress centre

BC Crisis Centre at 1-800-784-2433

Talk Suicide Canada at 1-833-456-4566

Suicide Crisis Helpline 988

Call 911.

**Please note that BeMorr Society is Not a Crisis line or Crisis centre. We provide mental health support.**

Name

First NameLast Name

Date of Birth

Address

Street Address

Street Address Line 2

CityProvince

Postal Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Preferred Contact Method:

Emergency Contact

First NameLast Name

Emergency Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Are you in need of Immediate support?

If you are in Immediate Crisis contact your local distress centre, or the BC Crisis Centre at 1-800-784-2433, Talk Suicide Canada at 1-833-456-4566, Suicide Helpline 988, or call 911

Please describe the urgency of your request.

What brings you to counselling at this time? (Check all that apply)

Are you currently experiencing thoughts of self-harm or suicide?

Which service are you interested in receiving?

Are you currently seeing another counsellor or therapist?

Have you received counselling before?

Have you received counselling supports from BeMorr Society before?

Is there a specific counsellor you would like to see? (Please see our Partnered Counsellor Bios) *we will try to accommodate your choice*

Do you currently have extended health benefits or insurance coverage for counselling?

Do financial barriers impact your ability to access counselling?

Would you be unable to access counselling without support from BeMorr society?

What type of support are you seeking?

My Annual Income level is

My Annual income is..

My budget is $(enter amount)* per month for counselling or other services.

BeMorr Society

What are you seeking?

If you are in Immediate Crisis