Intake Form

Summit Outreach and Counselling serves youth ages 15-25 in Saskatoon and area. Our services include One to One Addictions Counselling, Recreation, Outreach Services, and Group Education. There is no cost for our services. Contact us at 306-681-4911 or summitoutreachcounselling@gmail.com.

Confidentiality and Consent Agreement

I understand that information I share with Summit Outreach and Counselling is kept confidential, except where disclosure is required or permitted: by court order; to prevent suicide; to prevent violence towards others; where a child is in need of protection; and to prevent motor vehicle accidents.

By completing the form below, I consent to participate in Outreach Services and/or Addictions Counselling. Please check the consent box in the form and sign with your typed full name.

Referral Agency Information (if applicable)

If you were referred by an agency, please complete the referral agency section of the form below.

Client Information

Please complete the client information section of the form below.

Please enable JavaScript in your browser to complete this form.

Date

Client Name *

First

Last

Guardian Name (if applicable)

First

Last

Consent to Participate

• I consent to participate in Outreach Services and/or Addictions Counselling.

Client or Guardian Signature (typed full name)

Agency

Number

Email

List of completed Assessments

Guardian Treaty Other/General

Additional Comments

Name *

First

Last

Gender

Date of Birth

PHN

Treaty Number

Allergies/Restrictions

Phone Number

Email *

Address

Emergency Contact

Emergency Contact Phone Number

Services sought

• Addictions
• Outreach
• Other

Other/General Concerns

Submit