Single Parent Holistic Wellness Program Intake Form

Single Parent Holistic Wellness Program Intake Form

Care Masters Women and Family Services
Single Parent Holistic Wellness Program
A free, culturally responsive wellness program supporting Black, African, and Caribbean single mothers across Mississauga and Peel Region through therapy, wellness programming, creativity, movement, and community connection.

Participants may receive:
- 6 free virtual therapy sessions through Winrose Oasis Counselling
- Wellness and self-care programming
- Yoga, mindfulness, and breathwork experiences
- Creative arts and healing-centered activities
- Sister Circle peer support opportunities
- Childcare support assistance

All information shared through this intake form will remain confidential and used only to support your participation and wellness needs within this program.
Section 1 — Personal Information
First Name
Last Name
Preferred Name
Pronouns
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Contact Method
City
Postal Code
Cultural / Community Background, select all that apply
Country / Region of Origin
Primary Language Spoken at Home

Section 2 — Family & Children
Number of Children
Ages of Children, including adult children if applicable
Do you require childcare support in order to attend sessions?
How many children would require childcare support?
Employment Status
Emergency Contact Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to You

Section 6 — Consent & Agreements
Participation Acknowledgment: I understand that spaces in this program are limited and funded to support women in our community at no cost. I commit to communicating with the Program Coordinator if I am unable to attend a registered session or therapy appointment so that support opportunities can be offered fairly and respectfully to others.
I understand and agree
I confirm that I am a single mother residing in Mississauga or Peel Region and identify as part of the Black, African, or Caribbean community
Privacy & Communication Consent
Photo & Story Consent: Care Masters may occasionally share program photos, participant stories, testimonials, or wellness activities in reports, presentations, social media, grant updates, and community awareness materials to demonstrate impact, advocate for culturally responsive mental health supports, celebrate healing journeys, and inspire other women. We aim to share respectful, uplifting images that reflect participants with dignity and care.
Photo and Story Consent - Please select one
Digital Signature - I confirm that the information provided above is accurate to the best of my knowledge.
Full Name
Date

MonthDayYear
Date
Signature
Signature
Should be Empty:

Section 1 — Personal Information