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2026 Revised - Third Space Charity Counselling Application
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.
*
1.
First Name
(Required.)
*
2.
Last Name
(Required.)
*
3.
Phone Number
(Required.)
*
4.
Email
(Your counsellor will contact you via this email address)
(Required.)
*
5.
Where do you live?
We currently only serve those residing in Central Okanagan region of BC.
(Required.)
Kelowna
West Kelowna
Lake Country
Peachland
Summerland
Westbank First Nation
Okanagan Indian Band
Penticton
Vernon
Other (please specify)
*
6.
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
Clear
*
7.
Ethnicity or Culture of Origin (check all that apply)
(Required.)
Chinese
Japanese
South Asian or South East Asian
Korean
Latinx or Hispanic
Arab or West Asian
Black or African Canadian
Indigenous Person of Canada - Inuit, Metis, or First Nations
White or Caucasian
Pacific Islander
Other (please specify)
*
8.
Gender
(Required.)
Female
Male
Gender-fluid
Gender nonconforming
Non-binary
Two-Spirit
Genderqueer
Agender
Other (please specify)
*
9.
Do you identify as transgender?
Transgender, meaning your gender identity does not align with your assigned gender at birth.
(Required.)
Yes
No
Unsure
*
10.
How did you find out about Third Space?
(Required.)
Friend or word of mouth
UBCO Student Union building
UBCO Student Union social media or advertising
Referral from counsellor at UBCO Health and Wellness
Third Space Charity social media or advertising
Finished my sessions at UBCO Health and Wellness and needed access to more care
Referral from Okanagan College
Google or Search Engine
ChatGPT or other AI chatbot
Third Space Charity Event
Foundry
CMHA
Social Media
Details of referral or source:
*
11.
Is this your first visit with Third Space Charity?
(Required.)
Yes
No
12.
Do you have a gender preference or specific counsellor you would like to see?
Wait times may vary if a gender preference or specific counsellor is requested.
No
Yes
If yes, please specify.
13.
Please list your availability for counselling sessions (select all that apply)
Mornings
Afternoons
Weekdays
Weekends
Comments
14.
Please list your available locations for counselling sessions (click all that apply).
UBC Okanagan
Landmark 2 office
Online
Comments:
