LCSS Client Intake Form

Community Counseling

Community Counseling Intake Form

First Name *

Surname *

Gender *

Birthdate *

Primary Phone Number (With area code) *

Phone Type *

Secondary Phone Number (With area code)

Phone Type

Street Address *

City *

Postal Code

Your Email *

Referred By

Use this section to enter details on individuals living with Client. Leave addresses and phone numbers blank if they are the same as the Client’s Details.

Family Member Name (1)

Relationship with Client and age* if under 18

Address (Street, City, Postal Code)

Phone Number

Family Member Name (2)

Relationship with Client and age* if under 18

Address (Street, City, Postal Code)

Phone Number

Family Member Name (3)

Relationship with Client and age* if under 18

Address (Street, City, Postal Code)

Phone Number

Family Member Name (4)

Relationship with Client and age* if under 18

Address (Street, City, Postal Code)

Phone Number

Additional Family Members

Statistical Information

Geographic Location *

Family Structure *

History of Mental Issues *

History of Trauma *

History of Substance Abuse *

Current Substance Abuse Issue (Alcohol or Drugs) *

If Yes please Specify the CURRENT substances

Is the Ministry of Children and Family Development involved with your family in a protection capacity? *

Presenting Issues/Reasons for Counselling

Relevant Medical History (Hold Ctrl to select multiple)

Previous Direct Service/Supports (Hold Ctrl to select multiple)

Availability (Hold Ctrl to select multiple)

We acknowledge that our work takes place on the traditional and unceded lands of the Kwantlen, Matsqui, Katzie, and Semiahmoo First Nations. As well, we acknowledge the Inuit and Metis Nations peoples who live and work on these lands.

Langley Community Services, 5339-207 Street, Langley, BC V3A 2E6
Email: info@lcss.ca | Phone: 604 534 7921 | Fax: 604 534 3110

Langley Welcome Center #100 6470-201 Street, Langley, BC V2Y 2X4

ADDRESS	Langley Community Services Society 5339 207 Street Langley, BC V3A 2E6
EMAIL	info@lcss.ca
PHONE	604 534 7921
FAX	604 534 3110