Thank you for reaching out to Centre for Sexuality. 

This form includes some quick questions that will help our Intake Coordinator to determine which resources, referrals or supports will be most helpful to you. This may involve booking services with us, or a referral to alternative resources if our services are not the best match for your needs.

*In order for our Intake Coordinator to properly assess a client's needs, it is important that the client completes this intake survey themselves (rather than a person completing the survey for them). If you are looking into our services on behalf of someone who requires support completing this survey, please assist them. If you would prefer to complete this intake over the phone, please contact us at 403-283-5580 and ask to speak with the Intake Coordinator. 


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* 1. Name:

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* 2. Age:

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* 3. Pronouns:

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* 4. Phone Number:

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* 5. Can we leave a voice message at this number?

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* 6. Email:

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* 7. How did you hear about Centre for Sexuality?

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* 8. What is the main topic/concern that you would like to discuss in the session? 

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* 9. What is your goal for the session? (i.e. What do you hope to get out of speaking with a member of our staff?):

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* 10. Some of our staff offer sessions for folks with disabilities. Is this the type of session you are looking to book?

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* 11. Do you currently have access to medical insurance coverage for counselling services? (Please note: Services at Centre for Sexuality are provided free of charge. Your answer to this question will only be taken into consideration if a referral to additional services is required):

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* 12. Is there anything else you would like us to know about you? 

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