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HELP Line Intake Form

Please complete the form below, and a Clinician will contact you as soon as possible.

By completing this form your consent for services is implied. Services may include a team collaboration with either your child’s school and/or student support services such as Social Work and/or School Psychologist. The information gathered by your support team will be kept confidential. There are some limitations to confidentiality that may require a release of information without consent. These are, if there is a risk of child abuse, if there is a risk of suicide and if there is a risk of homicide. Information may also be shared under the Protecting Children Information Act. *

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I provide my consent to the above information.

Your name:*

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Your phone number:*

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Your mailing address:*

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List all students requiring support. Include their name, school and grade level:*

(ex: Jane Smith, Goose Lake High School, Grade 9)

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Your relationship to the above student(s):*

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Reason for requesting support:*

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Confirmation Email

Enter your email address here if you'd like to receive a confirmation upon submitting the form.

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