Counselling Request Form | My Neighbour's Keeper

Skip to main content

My Neighbour's Keeper

About Us
How We Help
Get Involved
- Become a Volunteer
- Start a Fundraiser
Ways to give
Resources

About Us
How We Help
Get Involved
- Become a Volunteer
- Start a Fundraiser
Ways to give
Resources

Donate

MNK Mental Health Counselling In-take Form

First Name

Last Name

Street Address

City

State/Province

ZIP / Postal Code

Date of birth *

Gender *

Marital status

Email address *

Home Phone

Cell Phone

Emergency Contact

Name *

Email address *

Phone number *

Emergency contact relationship *

Mental Health History

Present Concerns (check all that apply)Anxiety / WorryDepression / Low moodGrief / LossLoneliness / IsolationRelationship concernsStress / BurnoutAdjustment to life changesTrauma historySelf-esteem issuesOther

Why you are seeking counselling? *

What do you hope to achieve from counselling?

Are you currently under the care of a mental health professional?

Any recent hospitalizations?

Are you currently on Medication?

Preferred session days/times: *

Consent & Confidentiality *

I understand that:

My Neighbour's Keeper (MNK) counselling is confidential, except where required by law (risk of harm to self/others, abuse of a child/vulnerable person, or court order).
MNK is a non-emergency service and does not provide crisis intervention.

Counselling may include referrals to other resources where appropriate.

Stay in the know

Subscribe to receive updates on our impact and activities

Donate

We’re powered entirely by volunteers — people who give their time, skills, and hearts to serve others. With no paid staff, every donation goes to helping those in need.

Support us, give today.