MCS Youth Counselling Services & Emergency Shelter

ADMISSION – INTAKE FORM

Name: _Jack Da Costa______ Date of intake interview: _____16/10/18__

D.O.B.:__17/08/03____________ Health Card #: Client Refused to provide

Place of Birth: _Toronto_____ S.I.N #.: _Client Refused to Provide

Ethnicity: Portuguese ________________ Citizenship status: Canadian Citizen_

School: Rosedale School for the Arts_ Contact Person: _Bill Santos__________

Current Grade: ___10__ or Last grade completed: _________

Parent/s /Guardian/s

Name/s: Maria Da Costa___________________________________________

Address: 111 Grace street M5V 3E6______________________________

Phone #: 416-912-3871____________________________________________

Language spoken in the home: _Portuguese____________________________

Siblings: Name(s): Ages:

N/A

Family Contact Permitted: Y N Release of information consent: Y N

Circumstances of contact: In emergency situations only.________

Doctor’s Name: Unwilling to provide Phone #: Unwilling to provide

Address: UNWILLING TO PROVIDE____________________________

Date of last visit: UNWILLING TO PROVIDE______________

Medical Problems (allergies, diabetes, heart condition, etc.):

Unwilling to disclose and medical issues_____________________________________________________________________

____________________________________________________________________________________________________________________

Prescribed medication/s: UNWILLING TO PROVIDE Dosage: UNWILLING TO PROVIDE

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 MCS Youth Counselling Services & Emergency Shelter
ADMISSION – INTAKE FORM

Is there any history of the child/youth being abused?

Y N Confirmed Suspected

Type of Abuse: sexual physical emotional

N/A_______________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

What are the immediate short-term needs of the child or youth? (Your assessment & what the

youth has disclosed)

1. Counselling_____________________________________________________

2. School assistance/Tutoring__________________________________

3._____________________________________________________________________

4. ____________________________________________________________________

Y.C.J.A. Involvement? criminal record? Y N

Dates, charges, ongoing concerns, bail conditions:

N/A_______________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

Probation Officer: _____N/A________________________ Phone #______N/A__________________________________

Consent to release information: Y N

Upcoming court dates: Y N

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 MCS Youth Counselling Services & Emergency Shelter
ADMISSION – INTAKE FORM

Substance Use in past 3 months (approx. 90 days): Y N

Type (s) of drugs:

_Marijuana, Beer, Jack Daniels whiskey______________________________________________________________________

____________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________

How often is use? Does the youth have any concerns about their substance use or any negative

consequences?

Jack says he uses a couple times a month, he has no concerns as he is only experimenting and does

not believe there are any consequences involved with his usage.

____________________________________________________________________________________________________________________

NEEDS/QUESTIONS/CONCERNS OF CLIENT UPON INTAKE:

Jack says he is concerned over his feelings of depression and confusions as well as being concerned

over his parents fighting and his decreasing grades.________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

_ __________________________________________________________________________________________________________________

Date of follow up appointment: ___27/10/2018_________________________

Immediate follow up plan: Contact Bill Santos to confirm Jack has started counselling._______________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

Name of person completing the form: Andrew Gauvreau_________

Signature: _____________________________________________________

Signature of client: _______________________________________________