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Add Client Information

Referred by: Contact Person

Referred by:
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Referred by: Phone Number

Referred By: Email of contact person

Referral Date
Presenting Issue

Accompanying family members/Additional Notes

Does this client want Individual Counseling sessions?
Is the client taking any medications?
What medications are you currently taking?

Have you received any VAST services in the past?
First Name
Last Name
Birth Date
Male    Female    Other    Not Indicated GenderQueer    Prefer not to say   
Does this client identify as LGBTQ2S+?
Chosen Pronoun:

Phone Number
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Is it OK to leave a voice message?
Alternate Phone Number
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Postal Code
First Language
Languages Spoken
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Client Country of Origin:
Interpreter Required?
Is the client a minor?
If the client is a minor, please add Legal Tutor Name/Parent Name and phone number:

Where is this client:
How long has the client been in Canada?
Entry Pathway:
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Immigration status upon VAST intake
Landing Date
Refugee Hearing date as communicated upon intake:
Status of Hearing
Type of Hearing
Is the referral source requesting an assessment report?
Document Deadline
Lawyer Name

Lawyer Phone

Lawyer Email