Client Intake & Registration

This form gets us started. Nothing here is a diagnosis, a judgment, or a permanent record — it's just enough for us to walk alongside you well. You can skip any question that doesn't feel safe to answer yet.

About you

Full legal name *

Name you'd like us to use

Date of birth *

Pronouns

Best phone number *

Email *

Mailing address

Emergency contact

Emergency contact name *

Relationship *

Emergency contact phone *

How you found us

Who referred you?

Referrer name or detail (optional)

What brought you here

In your own words. No wrong answers.

What are you hoping we can help with? *

Who or what is already supporting you right now?

Payment

Heart of Care peer support is offered on a no-fee / sliding-scale basis. This section is only here so we know how to help you access other services when needed.

Autosaving as you type…