Thrive Client Intake Form

Full Name *

Phone Number *

Email address *

Address *

City *

Postal Code *

Date of Birth *

Gender *

Female

Male

Non Binary

Trans Man

Trans Women

2 Spirit

Prefer not to disclose

Do you identify as having a mental health condition? *

Yes

No

I'm not sure

Do you receive support from: (Check all that apply) *

VGH (inpatient/outpatient

UBC (inpatient/outpatient)

St. Paul's Hospital (inpatient/outpatient)

AAC

Mental Health Team

Other

Please provide a referral contact name *

Please provide a referral contact email address *

Please provide a referral contact phone number *

By checking the box, you give consent to us contact your referral

What is your goal for joining THRIVE *

Personal Development

Leisure Involvement

Social Involvement

Employment

Wellness Improvement

Life Skills

Stress Management

Where did you hear about this program ? *

After you have filled out our online form, please expect to hear back from us within 3-5 business days. Make sure to check your spam and junk email folder.