Ambrose SC Request Counselling Intake

Please complete the below form. If you are experiencing a crisis or any other urgent matter, please contact the 24/7 I.M. Well Clinical Response Centre at 1-877-554-6935 or go to the nearest hospital emergency room.
The counselling you are about to request is provided by your confidential I.M. Well Student Assistance Program.

Name First Last
Gender
Date of Birth / MM / DD YYYY
Are you a...
Current Student Alumni - Former Student Family Member
What type of counselling are you requesting?
Year of Studies
School issued email
Phone - ### - ### ####
City
Province
Please provide a brief description of the issue(s) for which you are seeking support
Have you ever received support or treatment in the past? If so, please briefly explain.
Are you currently experiencing any thoughts of hurting yourself or anyone else, or are you experiencing any violence or abuse?
Yes No
If yes, please explain:
Do you have any concerns related to alcohol or drugs?
Yes No
If yes, please explain:
In the past two weeks have you been feeling down or depressed?
Yes No
In the past two weeks have you been feeling anxious?
Yes No
May we contact you via your listed email address or phone number and leave a message?
Yes No