General Intake – STG Health Intake

General Intake Form

General Information

We’re here to help you on your journey to better mental health! To get started, please take a moment to book your priority intake for professional counselling.

Let's start with your name, phone number, email address, and birth date.

Your First Name

Your Last Name

Your Phone Number

Your Email

Date of Birth

Cultural Heritage

Now some questions about your Cultural Heritage. This section is essential to determine if you may qualify for NIHB or MN-SK funding.

Are you a Canadian Indigenous Person?

Please enter your full treaty card number

Please enter your MN-SK Citizenship number

Your Symptomology

Let's briefly look at your mental health symptoms and why you are seeking mental health supports.

Symptoms

	Present
Persistent anxiety
Persistent low mood
Persistent stress
I feel restless
Currently grieving
Persistent difficulties with sleeping
I feel tired all the time
Currently struggling with addictions

Over the last 2 weeks, how often have you been bothered by the following problems?

Little interest or pleasure in doing things

Feeling down, depressed or hopeless

Feeling nervous, anxious or on edge

Not being able to stop or control worrying

Are you currently taking prescription medication for your mental health?

Have you seen a mental health therapist within the last 12 months?

Do you have a letter from Victims Services SK with a case file number?

Intake Request

Select the service you are requesting an intake for and the desired time-frame.

What are you enquiring about?

When do you want to meet?

What would you like to discuss?

ADHD Specific Questions

Previously you selected ADHD Assessment. Please answer the following 6 questions as pre-screening for a potential ADHD assessment.

How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?

How often do you have difficulty getting things in order when you have to do a task that requires organization?

How often do you have problems remembering appointments or obligations?

When you have a task that requires a lot of thought, how often do you avoid or delay getting started?

How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?

How often do you feel overly active and compelled to do things, like you were driven by a motor?

Submitting your Intake Request

Please read the following carefully

- Submitting this form will forward my information to STG Health Services Inc. (La Ronge Branch).
- I understand that incomplete forms or inquiries irrelevant to counselling and requesting an intake appointment will be discarded.
- I understand that I will receive a text message and an email about making an intake appointment.
- I understand that submitting this form does not provide crisis management or urgent mental health support. If I need help now, I will call the Health Line 811 immediately or contact 911.
- All marketing and spam submissions will be deleted.

I agree and understand the above statements