GET IN TOUCH

USING OUR INTAKE FORM

If you or someone your know is in danger, please call 911.

If you need to talk to someone right away and you cannot reach us or it is outside of our hours, we recommend you contact 211 right away.

If you would like to use it to request services, please complete our intake form below.

Your privacy is important to us. We will not use your personal information for any purpose other than responding to your inquiry.

Date

YYYY

Name

First Name

Last Name

Date of Birth

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Cell Phone

(###)

###

####

Best number to reach you at

(###)

###

####

Can we leave you a voice message?

Please check one.

Email address

We will send you a reminder of your appointment once we set it up. Please provide email or phone # you want us to use.

Is this counselling for yourself or someone else?

Please check one. If this counselling counselling is for a child and there is a custody agreement and/or divorce/separation agreement, we require consent from both parents.

If this counselling is for someone else, please fill in the following fields.

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

YYYY

How did you hear about us?

Please check one. Is a social worker, employee, or other person recommending you seek counselling?

Have you had counselling in the past?

Please check one.

If yes, where and how long ago (approximately)?

What would you like to talk to a counsellor about?

In order to connect you with the right counsellor, please give as much information as you are comfortable with. All information is completely confidential.

Do you have any preference for time of day for your appointment?

Please check one.

In some circumstances we can provide phone or virtual counselling. Do you have a preference?

Please check one.

Do you have EAP coverage through your employer?

Please check one.

If yes, who is your employer?

Are you a client of Social Development?

Please check one.

Is your life impacted by the following:

Addictions

Violence - physical/emotional/sexual

Are the concerns you are reaching out about so significant you are considering suicide?

Please check one. To help ensure your needs are best addressed in a timely fashion, please consider reaching out to Mobil Mental Health at 1-888-811-3664 or contact 211 or 911.

To help reduce spam, we have added Google reCAPTCHA to our forms. Google reCAPTCHA prompts visitors to check a box to prove that they’re not a robot before they submit their information. In some cases, they’re also prompted to complete another task, like identify a string of letters or select specific images. This method makes it difficult for spambots to complete form submissions using strings of code to autofill and submit the form. This site uses reCAPTCHA V2.

Instead of having the form information stored in an online database, our form information is sent directly to Family Plus’ Intake Coordinator as an email. This means your information arrives on a secure computer, where it is reviewed and stored according to our normal security protocols for personal information.

Address

Suite 204 Linden Place
199 Chesley Drive
Saint John, NB E2K 4S9

Email
info@familyplus.ca

Phone
506-634-8295
Toll Free 800-360-3327