Client Information

Thank you for choosing Third Space Charity. Please complete all required questions in this survey, so we can learn how to best support you.

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1. First Name (Required.)

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2. Last Name (Required.)

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3. Pronouns

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4. Phone Number (Required.)

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5. Can this phone number receive texts?

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6. Email
(Your counsellor will contact you via this email address) (Required.)

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7. Emergency Contact Information
We will only contact this individual in the event of an emergency. (Required.)

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8. Where do you live?
We currently only serve those residing in Central Okanagan region of BC.  (Required.)

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9. Age
We serve individuals between the ages of 18 and 29. If you are outside this age range, see www.thirdspacecanada.org/resources for alternate community organizations. (Required.)

18 29
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i We adjusted the number you entered based on the slider’s scale.

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10. Ethnicity or Culture of Origin (Required.)

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11. Gender (Required.)

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12. Do you identify as transgender?
Transgender, meaning your gender identity does not align with your assigned gender at birth. (Required.)

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13. How did you find out about Third Space? (Required.)

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14. Is this your first visit with Third Space Charity? (Required.)

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15. If no, when did you last receive support from Third Space Charity?

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16. What was the name of your previous Third Space Charity counsellor?

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17. Do you have a specific counsellor you would like to see?
Wait times may vary if a specific counsellor is requested.

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18. Please list your availability for counselling sessions (select all that apply)

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19. Please list your available locations for counselling sessions (click all that apply).

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