Roman Catholic Archdiocese of St. John's

Client Name*

First Last

Date of Birth*

Gender (Self identify)*

Address*

Street Address Address Line 2 City Province Postal Code

May we email you?*

Please note that email correspondence is not considered to be a confidential medium of communication.

Yes
No

Email

Best Telephone #*

Leave Message?*

Yes
No

Source of Request

Self OR Name and Address of Agency.*

Name

First Name Last Name

Telephone # of Source

If not self-request, is the client in agreement with the request?

Yes
No

Service Requested:*

Individual Counselling
Couple Counselling
Family Counselling
Group

If Group, indicate name of group

How did you become aware of our services?*

PLEASE NOTE:
Ruah staff member will be in contact with you within five (5) business days for appropriate follow up.
Ruah is not a crisis centre. If you require help immediately, please phone the Mental Health Crisis Line at: 1-888-737-4668 or go to your nearest Emergency Department.

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Ruah Counselling Centre

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Ruah Counselling Centre

Source of Request

Ruah Counselling Centre

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