Intake Form

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.

All information on this form is received in confidentiality. Please note this form allows us to contact you in order to provide support and information on next steps.

If you are making a referral from an agency, please email contactus@stepniagara.ca for an agency referral form.

*Please note – if you are having technical issues filling out this form please email contactus@stepniagara.ca

 

What happens when I call and fill out the intake form?

Once you reach out, whether by phone or by filling out our intake form on our website, we then schedule an intake appointment. The appointment is 50 minutes with one of our qualified counsellors and will be a relaxed conversation sharing our Step services and policies, hearing about yourself, and figuring out how we can help you out. We are interested in providing you with a circle of care ensuring we are helping you to create a plan that works for you – working together to help you take those next “steps”. You can come as many times as needed. We also make referrals on your behalf to better accommodate and meet your physical, mental, emotional, social, and spiritual needs.

There is no cancellation fee, but out of respect we request at least 3 days’ notice if you are unable to make an appointment, except in the case of emergencies. Text cancellations or phone calls would be appreciated.

Starting in January 2024 we will be offering virtual, online, counselling sessions and we will also be renovating to allow for more accessibility.

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Guardian/Caregiver Name if under 16
If you are under 16 years old, please provide guardian/caregiver information so the STEP Staff is able to schedule an appointment for you.
Legal Name
Date of Birth
Preferred contact method
Do we have permission to leave a voice message?
Address
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