CARMIS Smart Forms - Aurora Family Therapy Centre

Template Client Intake Form

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Your Personal Details

Prénom*

Middle Name

Nom de famille

Preferred/Other Name

Date de naissance*

Marital Status*

Genre*

Level of Education

Email Address*

Phone Number*

Téléphone secondaire

Preferred Language*

Other Spoken Languages (if applicable)

Current Residential Address

Adresse*

Apt/Unit #

Ville

Province*

Code Postal*

Immigration Related Information

Statut au Canada*

UCI/IUC (Unique Client Identifier)*

UCI/IUC (Unique Client Identifier)

Pays de naissance

Date d'arrivée

How Did You Hear About Us

Emergency Contact Information

Nom et prénom*

Phone Number*

E-mail*

Prestations de service

Which type of services are you interested in:*

Would you like to provide any additional information

Details of Family Members

Would you like to register your family members so that they can also receive services with us?

Oui

Non

How many members would you like to add?*

Member 1

First Name (Member 1)*

Last Name (Member 1)

UCI/IUC (Unique Client Identifier) (Member 1)

Date of Birth (Member 1)*

Relation with you*

Gender (Member 1)*

Member 2

First Name (Member 2)*

Last Name (Member 2)*

UCI/IUC (Unique Client Identifier) (Member 2)

Date of Birth (Member 2)*

Relationship (Member 2)*

Gender (Member 2)*

Member 3

First Name (Member 3)*

Last Name (Member 3)*

UCI/IUC (Unique Client Identifier) (Member 3)

Date of Birth (Member 3)*

Relationship (Member 3)*

Gender (Member 3)*

Member 4

First Name (Member 4)*

Last Name (Member 4)*

UCI/IUC (Unique Client Identifier) (Member 4)

Date of Birth (Member 4)*

Relationship (Member 4)*

Gender (Member 4)*

Member 5

First Name (Member 5)*

Last Name (Member 5)*

UCI/IUC (Unique Client Identifier) (Member 5)

Date of Birth (Member 5)*

Relationship (Member 5)*

Gender (Member 5)*

Member 6

First Name (Member 6)*

Last Name (Member 6)*

UCI/IUC (Unique Client Identifier) (Member 6)

Date of Birth (Member 6)*

Relationship (Member 6)*

Gender (Member 6)*

Consents and Confidentiality Statement

Mail Consent

I consent to be added to VDICSS's mailing list for information on events and workshops.

The Agency protects personal information by following the government's privacy laws as outlined in the Personal Information Act, Bill 38: http://www.leg.bc.ca/37th4th/3rd_read/gov38-3.htm

Staff will not disclose any information without client permission unless legally obligated to do so. Completion and submission of this intake form implies consent to collecting information for these purposes.

By signing below and submitting this form, you confirm that you have read the Gathering Information statement and has given consent to future Immigration, Refugees, and Citizenship Canada Research/Consultation.

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