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Add Client Information

First Name

Last Name

Birth Date

Gender Male    Female    Other    Not Indicated GenderQueer    Prefer not to say

Does this client identify as LGBTQ2S+?

Yes      No

Chosen Pronoun:

Phone Number  -  -

Is it OK to leave a voice message?

Yes      No

Alternate Phone Number  -  -

International/WhatsApp Number

Email

Address   Unit

City Not SelectedAbbotsfordBurnabyCampbell RiverChilliwackCloverdaleCoquitlamDeltaGibsonHopeKamloopsKelownaLangleyMaple RidgeMissionNanaimoNew WestminsterNorth DeltaNorth VancouverPort CoquitlamPort MoodyPrince GeorgeRichmondSalt Spring IslandSouth DeltaSurreyVancouverVictoriaWest VancouverWhistler

Postal Code

First Language

Not SelectedEnglishFrenchAdaAffarAfrikaansAkaAkanAklanonAkraAlbanianAmerican Sign Language (ASL)AmharicArabicAranArmenianAshantiAssyrianAzeriBambaraBantuBauleBelenBembaBengaliBeniBeninBerberBicolBijaiyaBiniBisayaBissaBontokBraille (translation only)BretonBulgarianBurmeseBusanBusangoCantoneseCatalanCebuanoChakmaChaldeanChaochoChavacanoChichewaChiuchowChiyaoChowchauConcaniCreoleCroatianCzechDanishDariDeaf-MuteDioulaDutchEdoEfikEstonianEweFacilitatorFangFantiFarsi (Persian)FinnishFlemishFoochowFoukiFoullahFukineseFulaniGaGaelicGermanGreekGuerzeGujaratiHainamHakkaHararaHararyHargarHassanyaHausaHebrewHiligaynonHindiHindkoHokkinHungarianIbibioIboIcelandicIgorotIlongoIlicanIndonesianIshanItalianIziJapaneseJavaneseJolayKacchiKakwaKanareseKandahariKankaniKarenKashmiriKhmerKihavuKikongoKinyarwandaKirundiKiswahiliKonkaniKoreanKrioKurdishLa langue des signes québécoise (LSQ)LaotianLatvianLebaneseLengieLingalaLithuanianLowmaLugandaLugishuLutoroMacedonianMacenaMacuaMahouMakondeMalagasyMalayMalayalamMaligoMalinkeMalteseMandarinMandingoMarathiMashiMendeMinaMizoMongolianMoreNepaliNorwegianNzimaOkpeOriyaOromoOsalOther African languagesOther Chinese DialectsOther European languagesOther Languages NesOther Middle Eastern languagesOther Signed LanguagesOther South Asian languagesOther South East Asian languagesOther Western Hemisphere Indian languagesPahariPampangoPashtoPeulPhuockienPidginPlautdietsch (Mennonite Low German)PolishPortuguesePoularPunjabiRomanianRukigaRunyankoleRussianRutooroSamoanSangoScoulaSechuanSerbianSerbo-Croat-BosnianSesothoSeswiSeychellesShanShanghaiShansaiSindhiSinhaleseSlovakSloveneSomaliSoninkeSothoSoussouSpanishSuesueSukumaSwahiliSwazaiSwedishTagalogTaichewTamilTariTatshaneseTeluguTeochewThaiTibetanTichiewTigrignaTiminiTivToishanTsibulaTurkishTwiUhroboUigrigmaUkrainianUmbunduUnamaUrduUzbekVietnameseVisayanWarayWelshWolofXhosaYiboeYiddishYorubaZshilubaZugandaZuluMontenegrin

Languages Spoken

English French Ada Affar Afrikaans Aka Akan Aklanon Akra Albanian American Sign Language (ASL) Amharic Arabic Aran Armenian Ashanti Assyrian Azeri Bambara Bantu Baule Belen Bemba Bengali Beni Benin Berber Bicol Bijaiya Bini Bisaya Bissa Bontok Braille (translation only) Breton Bulgarian Burmese Busan Busango Cantonese Catalan Cebuano Chakma Chaldean Chaocho Chavacano Chichewa Chiuchow Chiyao Chowchau Concani Creole Croatian Czech Danish Dari Deaf-Mute Dioula Dutch Edo Efik Estonian Ewe Facilitator Fang Fanti Farsi (Persian) Finnish Flemish Foochow Fouki Foullah Fukinese Fulani Ga Gaelic German Greek Guerze Gujarati Hainam Hakka Harara Harary Hargar Hassanya Hausa Hebrew Hiligaynon Hindi Hindko Hokkin Hungarian Ibibio Ibo Icelandic Igorot Ilongo Ilican Indonesian Ishan Italian Izi Japanese Javanese Jolay Kacchi Kakwa Kanarese Kandahari Kankani Karen Kashmiri Khmer Kihavu Kikongo Kinyarwanda Kirundi Kiswahili Konkani Korean Krio Kurdish La langue des signes québécoise (LSQ) Laotian Latvian Lebanese Lengie Lingala Lithuanian Lowma Luganda Lugishu Lutoro Macedonian Macena Macua Mahou Makonde Malagasy Malay Malayalam Maligo Malinke Maltese Mandarin Mandingo Marathi Mashi Mende Mina Mizo Mongolian More Nepali Norwegian Nzima Okpe Oriya Oromo Osal Other African languages Other Chinese Dialects Other European languages Other Languages Nes Other Middle Eastern languages Other Signed Languages Other South Asian languages Other South East Asian languages Other Western Hemisphere Indian languages Pahari Pampango Pashto Peul Phuockien Pidgin Plautdietsch (Mennonite Low German) Polish Portuguese Poular Punjabi Romanian Rukiga Runyankole Russian Rutooro Samoan Sango Scoula Sechuan Serbian Serbo-Croat-Bosnian Sesotho Seswi Seychelles Shan Shanghai Shansai Sindhi Sinhalese Slovak Slovene Somali Soninke Sotho Soussou Spanish Suesue Sukuma Swahili Swazai Swedish Tagalog Taichew Tamil Tari Tatshanese Telugu Teochew Thai Tibetan Tichiew Tigrigna Timini Tiv Toishan Tsibula Turkish Twi Uhrobo Uigrigma Ukrainian Umbundu Unama Urdu Uzbek Vietnamese Visayan Waray Welsh Wolof Xhosa Yiboe Yiddish Yoruba Zshiluba Zuganda Zulu Select All

Country of Origin

Not SelectedAfghanistanAlbaniaAlgeriaAngolaAntiguaArgentinaArmeniaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBhutanBoliviaBosniaBotswanaBrazilBruneiBulgariaBurkina FasoBurmaBurundiCambodiaCameroonCanadaCarbiaChadChileChinaColombiaComorosCosta RicaCroatiaCubaDemocratic Republic of CongoDemocratic Republic of CongoDominican RepublicEcuadorEgyptEl SalvadorEnglandEritreaEthiopiaFijiFranceGambiaGermanyGhanaGrenadaGruyanaGuatemalaGuineaGuyanaHaitiHollandHondurasHong KongHungaryIcelandIndiaIndonesiaIndonisiaIranIraqIsraelItalyJamaicaJapanJordanKazahkstanKazakhstanKenyaKoreaKosovoKurdistanKuwaitKyrgyzstanLaosLatviaLebanonLiberiaLibyaMacedoniaMalawiMalaysiaMexicoMoldovaMongoliaMontenegroMoroccoMyanmarNepalNicaraguaNigeriaNorth KoreaOtherPakistanPalestinePanamaPapua New GuineaPeruPhilippinesPolandPortugalRomaniaRussiaRwandaSaudi ArabiaSenegalSerbiaSierra LeonSierra LeonaSierra LeoneSlovakiaSolomon IslandsSomaliaSouth AfricaSouth KoreaSpainSri LankaSt. LuciaSt. VincentSt.LuciaSudanSwazilandSwitzerlandSyriaTaiwanTanzaniaThailandTibetTogoTrinidadTurkeyUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUSAUzbekistanVenezualaVenezuelaVietnamYememYemenYugoslaviaZambiaZimbabwe

Interpreter Required?

Yes      No

Is the client a minor?

Yes      No

If the client is a minor, please add Parent/Legal Guardian/Legal Tutor Name and phone number:

Where is this client:

Inside Canada Outside Canada

Landing Date

Accompanying family members/Additional Notes

How long has the client been in Canada?

Not Selected1-4 yrs5-10 yrs10+ yrs

Entry Pathway:

Inland Claimant (Submitted claim for refugee inside Canada) Port of Entry Claimant (Claimed Refugee status at a border crossing: land, airport etc) Government Assisted Refugee (GAR, Refugee application sponsored by Government of Canada) Privately Sponsored (Refugee application supported by a group of people or organization Blended Visa (BVOR, Refugee application supported by a group of people and the Government of Canada) Foreign Student (Submitted/approved study permit application) Is Not a Newcomer Foreign Worker (Submitted/approved work permit application) Immigrant (Submitted Application through non-refugee pathway, Express Entry etc..) Temporary Foreign Worker Visitor (approved visitor visa application) CUAET (Submitted application for Ukrainians) Unknown (Unsure, or did not mention) Crisis in Gaza (Palestinian nationals who left Gaza after September 1, 2023) Asylum Seeker (Intend/In process to submit a refugee application)

If privately sponsored or BVOR, please fill out the following:

Sponsor's First Name

Sponsor's Last Name

Sponsor's phone number

Sponsor's email

Immigration status upon VAST intake

Refugee Claimant Failed Refugee Claimant Convention Refugee/Protected Person (approved refugee claim)  Permanent Resident Naturalized Citizen Temporary Foreign Worker Foreign Student PRRA/H&C New PRRA Temporary Displaced Persons Temporary Resident (Visitor, Temporary Resident Permit Holder) Open Work Permit For Vulnerable Workers Refugee Appeal  Unknown Restoration of Status (In process)/ Precarious Status Judicial Review

Refugee Hearing date as communicated upon intake:

Status of Hearing

Postponed, no new date yet      Not yet set      Scheduled      Rescheduled

Does the client have an immigration lawyer/consultant?

Yes      No

Lawyer Name

Lawyer Phone

Lawyer Email

Referred by: Contact Person

Referred by:

AKHB Archway Belkin House Bridge Clinic Burnaby Family Life Chimo Church Community Mental Health Team DiverseCity DTES FNHA Fraser Health Hospital Interior health island health ISSofBC Journey Home KCR Kinbrace Lawyer MCFD MOSAIC Mosque Neighborhood Houses northern health Options Community Services Other  PACE Society Private Sponsor Providence health Qmunity Rainbow REACH Clinic Red Cross Roots Salvation Army School School Counsellor School District Self-referral SOS SUCCESS Three Bridges Umbrella VCH VGH B-Hired/Skills Hub Select All

Referred by: Phone Number

Referred By: Email of contact person

If you are from a health or mental health institution please answer these questions:

Did the client ever receive services from you?

Yes      No

If yes, what type of services and for how long?

If you are not continuing your services with this client, please specify the reason:

We only offer limited number of sessions We only offer crisis counselling We don’t have the right languages We aren’t equipped for complex trauma We aren’t equipped for migration/settlement related supports Others - please explain  Select All

Referral Date

Reason for Referral

Individual Counselling    Group    Select All

Is the Client requesting the above services?

Yes      No

If Individual Counselling, please check off current concerns relevant to clients situation below:

Grief related to Migration Culture Shock/Adjustment Sleep Problems Problems with memory and concentration Depressed Mood Diagnosis of PTSD Feelings of Anxiety Suspected PTSD Immigration Related Stress Other  Select All

If Other, please add some brief additional information in the box below:

Is the client taking any medications?

Yes      No

If yes, please list medication if applicable or available:

Did the client ever receive a diagnosis?

Yes      No      I don't know

If yes, please specify the diagnosis and the country where it was made

Is the client currently receiving psychiatric or psychological services?

Yes      No

If yes, please specify:

Have you received any VAST services in the past?

Yes      No

All information you provide will be kept strictly confidential. To submit this form please review then click Save.