Counselling Intake Form

Your safety and well-being matter to us

KPU Counselling Services is aware that students may experience situations that are serious, emotionally distressing and/or require immediate attention. Because our intake drop-ins are first come, first served, it’s important that you let us know if any of the following apply to you today:
If you answered “Yes” to any of the above situations, please inform our Counselling Assistant. You do not need to provide any details to the Assistant. A counsellor will speak with you to briefly assess your situation and recommend how to proceed.
Contact Information
To contact you about appointments
If different from above
In case of emergency
Current Term
Availibility Option 1
Availibility Option 2
Availibility Option 3
On the schedule below please select the times you are ABLE to attend counselling this term and your preferred campus location.
Counselling Intake
If different from above
Reasons for seeking counselling

How much does this interfere with your:

Do you take any of the following?
E.g. Ritalin, Dexedrine, Caffeine
E.g. Cocaine, Ecstasy, Meth, Mushrooms, Heroin
Please check any items that you are currently concerend about and at what level
Safety Concerns

KPU Counselling Services takes the protection of your privacy very seriously. In accordance with our professional association’s ethical guidelines, all information discussed and/or recorded during counselling sessions is considered private and is held in strict confidence. Your counsellor may consult with counsellor colleagues to ensure that you are receiving the best care possible. All clinical notes are accessible to counsellors at KPU. We will not release information to anyone, whether an individual or an agency, without your consent.

Exceptions to confidentiality include:

  • Duty to warn if you or someone you know is in imminent danger or at risk
  • When there is reasonable cause to believe a child is in need of protection
  • When there is a court order to release records

Please note that we cannot ensure the confidentiality of communication via email and cell phones.

If you need to miss an appointment for any reason, we require minimum notice of 48 business hours to cancel. Failure to provide adequate notice or “no shows” may result in termination of services.