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

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* 2. Last Name

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* 3. Pronouns

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* 4. Phone Number

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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)

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

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

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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.

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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

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* 11. Gender

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

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* 13. How did you find out about Third Space?

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* 14. Is this your first visit with Third Space Charity?

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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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