Newcomer Mental Health Program Initial Eligibility Screen

Aurora Family Therapy Centre provides mental health services to newcomer individuals, couples and families who are facing challenges in their day-to-day life due to experiences of PTSD/trauma and mental health issues.

The following questions are designed to help determine whether you meet the requirements for our program. Please be as open as possible as it will help to determine the supports and resources we can help you with. You do not have to answer any question if you don’t want to.

Hidden

Date (Admin-only)(Required)

First Name(Required)

Last Name(Required)

UCI Number (Optional)

Date of Birth (Optional)

Are you a newcomer to Canada?

Immigrant Category

Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For example:

a serious accident or fire
an earthquake or flood
a physical, emotional or sexual assault or abuse
a war or conflict
seeing someone be killed or seriously injured
having a loved one die through homicide or suicide
persecution based on age, race, ethnicity, sexual orientation, gender identity, political views, etc.

Have you ever experienced an event of the kind described above?

In the past month have you...

Had nightmares about the event(s) or thought about the event(s) when you did not want to?

Tried hard not to think about the event(s) or went out of your way to avoid situations that reminded you of the event(s)?

Been constantly on guard, watch, or easily startled?

Felt numb or detached from people, activities, and your surroundings?

Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused?

Have you ever met with a psychologist or psychiatrist?

If yes, do you have any formal mental health diagnoses?

Do you have any additional comments?