Sleep (Insomnia) Intake Sleep IntakeΔ Updates General InformationWe’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 NameYour Last NameYour Phone NumberYour EmailDate of BirthSave & ResumePreviousNextCultural HeritageNow 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?- Select -NoYes, First Nations or InuitYes, but non-statusYes, MN-SK CitizenPlease enter your full treaty card numberPlease enter your MN-SK Citizenship numberPreviousNextYour SymptomologyLet's briefly look at your overall mental health symptoms.SymptomsPresentPersistent anxietyPersistent low moodPersistent stressI feel restlessCurrently grievingPersistent difficulties with sleepingI feel tired all the timeCurrently struggling with addictionsOver the last 2 weeks, how often have you been bothered by the following problems?Little interest or pleasure in doing things- Select -Not at allSeveral daysMore than half the daysNearly every dayFeeling down, depressed or hopeless- Select -Not at allSeveral daysMore than half the daysNearly every dayFeeling nervous, anxious or on edge- Select -Not at allSeveral daysMore than half the daysNearly every dayNot being able to stop or control worrying- Select -Not at allSeveral daysMore than half the daysNearly every dayAre you currently taking prescription medication for your mental health or for sleep?- Select -NoYesHave you seen a mental health therapist within the last 12 months?- Select -NoYesDo you have a letter from Victims Services SK with a case file number?PreviousNextSleep Specific QuestionsPlease answer the following 6 questions as pre-screening. Please rate the CURRENT SEVERITY (i.e. last two weeks) of your sleeping problem(s).Difficulty falling asleep- Select -NoneMildModerateSevereVery SevereDifficulty staying asleep- Select -NoneMildModerateSevereVery SevereProblems waking up too early- Select -NoneMildModerateSevereVery SevereHow SATISFIED/DISSATISFIED are you with your CURRENT sleep pattern?- Select -Very SatisfiedSatisfiedModerately SatisfiedDissatisfiedVery DissatisfiedHow NOTICEABLE to others do you think your sleep problem is in terms of impairing the quality of your life?- Select -Not NoticableA LittleSomewhatMuchVery Much NoticableHow WORRIED/DISTRESSED are you about your current sleep problem?- Select -Not WorriedA LittleSomewhatMuchVery Much WorriedTo what extent do you consider your sleep problem to currently INTERFERE with your daily functioning (e.g. daytime fatigue, mood, ability to function at work/daily chores, concentration, memory etc)?- Select -Not InterferingA LittleSomewhatMuchVery Much InterferingWhat would you like to discuss / Please provide additional informationPreviousNextSubmitting your Intake RequestPlease read the following carefully - Submitting this form will forward my information to STG Health Services Inc. - 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 Previous Request Priority Intake
