Beyond Able Group Intake Form

Welcome to MASC!

The information you provide is confidential, and will be helpful for your counsellor to learn more about your situation and how best to be of help to you.

If you have any questions, please ask.

Intake Form

Full Name Date of Birth Email Address Phone Number

Emergency Contact (Name & Phone)

Insurance Information

Insurance provider & name of insured Certificate #

About Your Family

Relationship to the Child (e.g. father, uncle, mentor) Age of Child(ren) Child’s Diagnosis or Area of Challenge (if known)

Support Needs

What motivated you to join this group? What are you hoping to gain?

Have you participated in a support group before? YesNo

Is there anything the facilitator should know to best support you?

Policy Agreement I confirm that I/we have reviewed and agree to the policies regarding therapeutic support, including attendance, confidentiality, and deposit requirements. I/we understand that these policies apply to my participation.

You can review all policies here: Forms & Resources .