Outreach Program Intake Form

Your Name (first & last)*:

Date of Birth*:

Address (we do not mail anything to you)*:

City*:

Phone Number*:

Is it safe to call?*
YesNo

Is it safe to leave messages?*
YesNo

Email Address*:

Is it safe to email?*
YesNo

How did you find out about our services?*

Have you used Anova services in the past?*
YesNo

Your preferred language is*:

Citizenship/Immigration Status*:
—Please choose an option—Canadian CitizenPermanent Resident/Landed ImmigrantStudent VisaRefugeeVisitor/No StatusI prefer not to answer

What gender do you identify as?*
—Please choose an option—FemaleMaleTransgenderNon-Binary or another not listed

Your preferred pronouns (optional)*:

Do you think of yourself as*:
—Please choose an option—Straight/HeterosexualLesbian/Gay/HomosexualBisexualAnother orientation not listedI prefer not to answer

Do you identify as First Nations, Métis, and/or Inuit?*
NoYes

If yes:
—Please choose an option—First NationsMetisInuit

—Please choose an option—StatusNo Status

—Please choose an option—On ReserveOff Reserve

Which of the following best describes your racial or ethnic group?*
Black African (Afro-Caribbean, African Canadian descent)East/Southeast Asian (Chinese, Korean, Japanese, Taiwanese, Filipino, Vietnamese, Cambodian, Thai, Indonesian, other Southeast Asian)Indigenous/Native (noted above)Latino (Latin American, Hispanic descent)Middle Eastern (Arab, Persian, West Asian e.g., Afghan, Egyptian, Iranian, Lebanese, Turkish, Kurdish)South Asian (East Indian, Pakistani, Bangladeshi, Sri Lankan, Indo-Caribbean)White (European descent)Another race category not described aboveI prefer not to answer

Children Information

Child #1

First and Last Name:

Date of Birth:

Gender:
—Please choose an option—FemaleMaleTransgenderNon-Binary or another not listed

Child #2

First and Last Name:

Date of Birth:

Gender:
—Please choose an option—FemaleMaleTransgenderNon-Binary or another not listed

Child #3

First and Last Name:

Date of Birth:

Gender:
—Please choose an option—FemaleMaleTransgenderNon-Binary or another not listed

Child #4
First and Last Name:

Date of Birth:

Gender:
—Please choose an option—FemaleMaleTransgenderNon-Binary or another not listed

Identified Abuser

Confidentiality Agreement

• If Anova has reason to believe that I am going to hurt myself or someone else, Anova has an obligation to call the London Police and connect me with the support I need.

• If Anova has reason to believe that a child under the age of sixteen is being abused or is at risk of being abused (including emotional harm which can be caused by witnessing domestic violence), Anova has a duty to report the information to the Children’s Aid Society.

• If the court requests a copy of your file, Anova is obligated to provide them with a copy of the entire file or any part that they wish to have. Anova can also be asked to testify in your case.