SAC Brant Counselling Intake E-Form Name First Name Last Name My Pronouns Please Contact Me By: Please Check All That Apply Phone Text Email Phone (###) ### #### Leave a Message? Is it okay/safe to leave a message if I don't answer. Yes No Text Number (###) ### #### Email Please Select All That Apply I am between the ages of 14 and 19 I live in the County of Brant I live in Brantford I would prefer In-Person sessions I would prefer Phone sessions I would prefer Video sessions Thank you. Your request has been received and will be reviewed. A member of our team will be in contact shortly.