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Resource Support Intake Form

Privacy and Consent Notice: All information you provide is kept strictly confidential and will never be shared without your explicit consent. Any data that is stored is used explicitly to provide appropriate care. Data will be stored for up to one year after intake call. We will contact you only upon your request and you may opt out at any time. Please be aware this is not an emergency service -- if you or the person you’re assisting is in crisis, please seek help immediately (https://www.mhsvictoria.org/crisis-information).

Please email us at support@mhsvictoria.org if you need any help with this form. 

Are you completing this form for yourself or on behalf of someone else?*
This does not need to be your legal name.
You're welcome to use an initial.
Pronouns*
How do you like to be addressed?
Do you identify with any of these?
This might help you access additional resources in the community.
Location*
We will use this to find catered resources based on your geographic region.
Previous Mental Health Support *
Have you previously received help for your mental health
Mental Health Diagnosis*
What cost of resources are you looking for?
Health Insurance*
We will use this to make sure resources we recommend are accessible to you.
What method of resources are you interested in?
Needs_resource
If your need wasn’t addressed above you can state it here or provide more information.
Please provide any additional information that you would like to expand on or let us know about.
Where did you hear about our Peer Support program?

Your email is never shared, and you can opt out at any time.