Application for Services

Health Information
Please indicate your Mental Health Diagnosis:
Please indicate any concurrent diagnosis or developmental disorder

Autism Spectrum Disorder, Learning Disability, Brain Injury, Dementia, Fetal Alcohol Spectrum Disorder (FASD)
Please indicate your Mental Health Clinician/Physician Contact Information
First Last
Psychiatrist/General Practitioner/Family Doctor/Nurse Practitioner (or Community Mental Health Worker/EI, EIA or EIA Disability Worker)
Group/Organization
Address
Street Address Address Line 2 City Province Postal Code
Phone
Fax
Email

Once you've submitted your application you will receive an email requesting your signature for authorization for release of information. Your signature is required in order for your application to be considered.
CAPTCHA
Number

Service Request