Intake Form

Immediate Safety

Are you in immediate danger? Are you in immediate danger? Yes No

Are you thinking about harming yourself or someone else? Are you thinking about harming yourself or someone else? Yes No

Do you have access to means of harm right now? Do you have access to means of harm right now? Yes No

If yes, please describe briefly:

Contact Information

Full Name or Alias

Preferred Name

Phone Number

Email Address

About You

Age Range Age Range18-3031-4545-6060 & over

Gender Identity

Location (City/Town, Province/State)

Primary Language

Specific communities you identify with (optional)

Reason for Contact

Main issue(s) you are facing today Main issue(s) you are facing today Suicidal thoughts Mental health crisis Abuse or violence Substance use Homelessness or housing crisis Relationship or family conflict Financial crisis Others

Please describe

How long has this been going on?

Is there anything that triggered this today?

Current Supports

Do you have a mental health professional or counsellor? Do you have a mental health professional or counsellor? Yes No

Do you have friends/family you can talk to? Do you have friends/family you can talk to? Yes No

Are you connected to any support services? Are you connected to any support services? Yes No

If yes, please describe

Consent & Confidentiality

Our services are confidential, except if we believe you are at risk of harming yourself, someone else, or if required by law. By submitting this form you agree to YLC responding/communicating with you via email. Our services are confidential, except if we believe you are at risk of harming yourself, someone else, or if required by law. By submitting this form you agree to YLC responding/communicating with you via email. Please confirm you have read and agree to our terms of terms of use

Would you like to receive a copy of this form by email? Would you like to receive a copy of this form by email? Yes No

Additional Information

Is there anything else you’d like us to know?