MVISS Intake Form Name * First Name Last Name Referral Agency Email * Phone * (###) ### #### Date of Birth * MM DD YYYY Community i.e. Vancouver, Richmond, North Shore, Surrey Gender Identity Female Male Two Spirited Transgender Non-Binary Prefer not to specify Sexual Orientation (Optional) First Nations Status Status Metis Inuit Other Non-Status If other, please specify: Marital Status Married Single Divorced Common Law Separated Widowed Spouses Name (If applicable) Personal health number: Family Doctor: Family Doctor's Phone Number (###) ### #### Emergency contact: * Relationship: Phone * (###) ### #### Address: Mental Wellness and substance use and other concerns: Are you using drugs or alcohol? If yes, what types of substances: Have you been diagnosed with psychological disorders (i.e. depression, anxiety, bipolar, schizophrenia, PTSD, etc. that required professional counselling? Yes No If yes, please elaborate: Have you ever been hospitalized for psychological reason? Yes No If yes, please tell us where, when, and for how long: Have you ever self harmed. (Cutting, burning, gashing) If yes how and how long ago)? Have you ever had suicide ideation? Yes No If yes, how long ago? Are you currently having ideation? If yes, do you have a plan? *Note* We will complete a safety plan with you if you are experiencing suicidal ideation Please use the below blank space to discuss more about the wellness issues you are facing (Optional): Residential School Have you attended residential school? Yes No If yes, how long did you attend residential school? Have your parents, siblings and / or relatives attended residential school? Yes No Unknown How long did your siblings, parents and / or relatives attend residential school? Which school did you attend? Which school did your parents attend? How has residential school impacted you? From this list, please tell me what you would like support with: ( Pick top 4 only please) Violence Grief Sexual Abuse Childhood Abuse Abandonment Shame Alcohol Drugs Prescription Drugs Gambling Sexual Addiction Mentoring / Coaching Life Skills Training Counselling, emotional and/or spiritual support Parenting Skills Training Family Support and Counselling Education Activities (like credit recover, tutoring, homework, school, etc.) Sobriety Sports Activites Arts Activites Recreational Activities Community service or volunteer work Cultural service or volunteer work Cultural activities/traditional learning/aboriginal programs Employment support (resume writing, interview skill, etc) Case Management Housing Support Outreach Cultural Identity Mental Wellness Foster / Adoption After care planning Other Traumas: Thank you! It can take 1 - 2 weeks to process your intake. If you wish to speak directly with the MVISS Intake Worker, please call 604-262-4355 or email intake@mviss.ca
