Book An Appointment

Intake Assessment

Is the youth or yourself at high risk today?


If Yes, then please contact Ministry for Child and Youth Mental Health (250) 861-7301,
Adult Mental Health (250) 868-7788, Crisis Line 1-888-353-2273
or the Adolescent Psychiatric Unit at Kelowna General Hospital (250) 862-4346
as we are not an emergency counseling service. Thank you.

General Information:

Youth's Date of Birth:






Gender:


Youth’s First and Last Name:



Address:



City:



Postal Code:



What number should we call to book appointments?



Secondary or Emergency Contact numbers:

Home:



Cell:



Work:



Parent(s) Cell:



Your Email or Parent's email address to confirm appointments:



If Under 19 - Indicate the Parent(s) or Gaurdian(s) who live with you, separated by comma:



Who referred you to reach out?



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