Application for Services

Contact Information
Need help filling out your application? Contact our Intake/Discharge Coordinator at 204-237-7165
Name*
First Middle Last
No Fixed Address
Please select this box if you do not have a home address.
Address*
Street Address Address Line 2 City Province Postal Code
More information:*
Preferred Method of Contact:*
Email*
Phone*
Email
Phone
Email Consent
I consent to receive emails from Sara Riel
By checking this box, you consent to receive emails regarding programming at Sara Riel, including information on groups/workshops, newsletters, and more.

Service Request
Need help filling out your application? Contact our Intake/Discharge Coordinator at 204-237-7165
Select the option that describes your application:*
- I am applying both for Seneca Respite and another Sara Riel service.
- I am only applying for another Sara Riel service.
- I am only applying for Seneca Respite.
Access to Seneca Respite Services requires a mental health professional contact and collateral. For this application, we can accept documentation from addictions agencies, medical practitioners, clinical social workers, mental health agencies, Crisis Stabilization Unit/Crisis Response Center Clinicians, nurse practitioners, hospital/psychiatric unit, psychologists, Klinic Social Workers, or psychiatrists.
Seneca Respite is for people struggling with their mental health who have determined they are facing an elevated need for mental health support and would benefit from a 5-night stay in a home-like, 24-hour peer supported environment. Learn more here
Please select the service you are applying for:*
- Community Mentorship
- Employment Services
- Mental Health Case Management
Mental Health Case Management is for people struggling with their mental health who would like help identifying their goals, working through emotions, and finding resources. Learn more here
Employment Services are for people struggling with their mental health who would like help finding and keeping meaningful employment. Learn more here
Community Mentorship is for people struggling with their mental health who would like help establishing task-based goals and support in developing/strengthening their independent living skills. Learn more here

Mental Health Information
Need help filling out your application? Contact our Intake/Discharge Coordinator at 204-237-7165
Please indicate your mental health diagnosis and/or current mental health/addiction concern*
Please indicate any concurrent diagnosis or developmental disorder

Autism Spectrum Disorder, Brain Injury, Dementia, Fetal Alcohol Spectrum Disorder (FASD), Learning Disability

Mental Health Professional Contact Information
Let us know who to contact to get documentation for your application to Seneca Respite Services. Need help filling out your application? Contact our Intake/Discharge Coordinator at 204-237-7165
Name*
First Last
Group/Organization*
Address*
Street Address Address Line 2 City Province Postal Code
Phone*
Fax
Email

Referral Source
Who referred you to Sara Riel?*
Who suggested or helped you apply to Sara Riel?
What organization referred you to Sara Riel?*
What event/place did you see Sara Riel at?*

Application Completion Consent*
I am submitting this application for myself or with a consenting individual.
By checking this box you confirm that you are either filling out this application for yourself or with a consenting individual who meets our admissions requirements”
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Contact Information

Demographic Information

Service Request

Mental Health Information

Mental Health Professional Contact Information

Referral Source

Struggling? Need to talk?
204-942-9276

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Application for Services

Contact Information

Demographic Information

Service Request

Mental Health Information

Mental Health Professional Contact Information

Referral Source

Struggling? Need to talk?204-942-9276

Struggling? Need to talk?
204-942-9276