Journeying Together Intake – Peterborough Journeying Together Intake - Peterborough Journeying Together offers education and support for caregivers and family members of individuals with mental health concerns. 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With 1 being “not so bad” and 10 being “crisis” and “needing immediate support”. * Required **if you are rating your problem at a “10”, please call 4 County Crisis at 1-866-995-9933. If you could choose only one thing to work on, what would that be? * Required What have you done so far to address the difficulty/problem? Has this been successful? * Required Diagnosis of my loved one If you are seeking support in the form of understanding the diagnosis of your loved one, please tell us their diagnosis. Other Presenting ConcernsDemographic InformationAre you a Canadian citizen? * Required Yes No Are you of Indigenous descent? * Required Yes No What is your preferred language? * Required What type of residence do you live in? * Required For example: house, apartment, shelter, hospital etc...Who do you live with? * Required What is your source of income? * Required Are you currently... * Required In school Working None What is the highest level of education you have completed? * Required Elementary Some high school High school Some college College/university Referral SourceReferral Source * Required Walk-In/Self Referral Community Agency Agency Name Worker Name First Last Name of worker at referring agencyContact Information Contact information for worker at referring agency.Is there written consent to share information? Yes No
