Survey - Black Mental Health Canada

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Thank you for your interest in seeking mental health services at Black Mental Health Canada (BMHC). We want to ensure that we can provide you with the best possible support. Kindly fill out this questionnaire to help us understand your preferences and needs.

Survey

Step 1 of 10

10%

Why are you visiting today?

Looking for a therapist

Looking to join a group

Interest in volunteering at BMHC

Looking to ask general questions

Are you looking for services for yourself
or someone else?

Myself

Someone else

Age Group:

Toddlers 0-6

Children 6-10

Pre-teen 10-12

Teen 13-18

Adult 18-64

Elderly 65 plus

Preferences for Therapist:

1. Are you looking for a male or female-identified therapist?

Male

Female

Not Important

2. Do you have an age preference for your therapist?

18 to 30

30 - 45

45 and older

Not important

3. Do you have a religious preference for your therapist?

Not important

Christian

Muslim

Hindu

Sikh

Buddhist

Other

Write down the religion

Experience and Qualifications:

1. Do you have a preference for years of experience?

0-5 Years

5 - 10 Years

11 to 20 Years

20 Years or more

2. Do you have a preference for someone with a particular sexual orientation?

Not Important

Gay

Bi-sexual

Lesbian

Trans-gender

Other

Write down the sexual orientation

Specific Symptoms (if any):

Specific Symptoms (if any):

Anxiety symptoms

Depressive symptoms

School-related/academic issues

Sexual issues

Identity issues

Sleep issues

Body image issues

Other

Write down your symptoms

Service Preferences:

1. Do you prefer Online or In-person sessions?

Online

In-person

2. Do you have a specific location preference?

Therapy Treatment Preferences:

Are you looking for a male or female-identified therapist?

YES

NO

List here

Appointment Time Preferences:

What is the preferred time of appointments?

In the morning

In the afternoon

In the evening

Your Ideal Therapist:

Please write a brief paragraph describing your perfect therapist and the qualities that matter most to you. Also, mention the type of therapist that would almost certainly not be a great fit for your personality.

Type here...

.

Δ

Business Hours:
9 AM - 5 PM, Monday to Friday
‎

© 2023 Black Mental Health Canada.

Home
About Us
Speaker’s Corner
- Programs
Workshops
Forum
Blog
News
Contact
- Get Involved
Register
Login
- Forgot Password?
Find a Mental Health Provider
Donate

NEED HELP NOW

The Black Youth Helpline Text or email: Talk Canada Suicide or Text Crisis Call Centre Wellness Together Canada, Text

1-833-294-8650 info@blackyouth.ca (833) 456-4566 45645 (800) 273-8255 741741

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