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.

Phone

This field is for validation purposes and should be left unchanged.

Ruah Counselling Centre

Request for Services

Ruah Counselling Centre

Source of Request

Ruah Counselling Centre

Contact Ruah Counselling Centre