Intake Form

Full Name

First

Last

Date of Birth

Format: MM/DD/YYYY

Gender

Male
Female
Prefer not to say

Contact Number

Format: (123)-456-7890

Email Address

Preferred Language

Current Address (City, Province/State)

Type of Assistance Requested

Spouse/Partner's Name

Date of Marriage or Start of Relationship

Format: MM/DD/YYYY

Years Married/Together

Date of Seperation (If applicable)

Format: MM/DD/YYYY

Are you currently living together?

Yes
No

Do you have children?

Yes
No

Number of Children

Ages of Children (e.g. 5, 9, 14)

Who are children currently living with?

Requested consent. or

What type of support are you seeking? (Tick all that apply)

Emotional/Family Counselling
Guidance on Separation/Divorce Process
Religious/Islamic Guidance
Child Custody / Parenting Support
Referral to Legal Professionals
Referral to Family Counsellors / Imams

Other (Please specify)

Short Description of Your Situation

Is there any immediate safety concern (Domestic abuse, threat, urgent child welfare issue)?

Yes
No

If Yes, would you like us to prioritize your case and connect you to emergency/community resources?

Yes
No

I understand that Rahmah Marital Services is a community support service and does not provide legal advice.

I understand that Rahmah Marital Services is a community support service and does not provide legal advice.

I consent to my information being used only for the purpose of connecting me with appropriate advisors, Imams, counsellors, or lawyers with my consent.

I consent to my information being used only for the purpose of connecting me with appropriate advisors, Imams, counsellors, or lawyers with my consent.

Signature (Type your full name & date)

Format: Your Full Name, Date Signed

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