Intake Form – STEP Niagara

This form is used only for self referral or guardian referrals If you are a youth under the age of 16 please fill out the required guardian information. If you are making a referral from an agency, please email contactus@stepniagara.ca for a referral form. *Please note - if you are having technical issues filling out this form please email contactus@stepniagara.ca

Legal Name(Required)

First Last

Guardian/Caregiver Name if under 16

First Last

If you are under 16 years old, please provide guardian/caregiver information so the STEP Staff is able to schedule an appointment for you.

Name

First Last

Date Of Birth(Required)

Please add your date of birth - year/month/day

Pronouns

Address

Street Address Address Line 2 City Province Postal Code

Phone(Required)

Email(Required)

Preferred contact method(Required)

Phone (Text)

Phone (Call)

Do we have permission to leave a voice message?(Required)

Yes

Please provide a brief description for the reason you are seeking counselling services.(Required)

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