Register a Client

Register a Client - New Item

⚠ There are items in this form that require your attention

Date *

Referring Source - First Name *

Referring Source - Last Name *

Referring Source - Email Address *

Referring Source - Phone Number *

Organization's Name

Name of the organization referring the client.

Client's Full Legal Name *

Client's Preferred Name

Client's Age *

Client's Phone Number *

Client's Email

Client's Address *

(Include City, Street Name and Number, Postal Code)

I understand that by providing these contact information, I confirm I have read and understood that

1- The youth consented to share their information with Dan's Legacy
2- The youth can provide informed consent to join the counselling program.
3- The youth will attend weekly sessions consistently for 16 weeks (about 4-5 months).
4- The youth is ready and willing to work on personal goals with a counsellor.
5- The youth is seeking steady, ongoing support rather than one-off or emergency help.
6- The youth does not currently have an ongoing need for urgent care or specialized intervention.

⚠ There are items in this form that require your attention