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Ontario
Self-Referral
Please tell us how we can help you
Indicate if the issue is related to Addiction, Mental Health, or Both:
Please tell us who you are
Salutation:
Mr
Mrs
Miss
Ms
* First Name:
Middle Name:
Last Name:
Preferred Name:
Date of Birth:
Age:
Gender:
Do not know
Female
Gender Non-Conforming
Intersex
Male
Other
Prefer not to answer
Trans / Transgender - Female to Male
Trans / Transgender - Male to Female
Two-Spirit
Please tell us how we can contact you
Preferred Language:
Akan
Algonquin
Amharic
Arabic
Armenian
ASL, (American Sign Language)
Athapaskan languages
Atikamekw
Bengali
Bisayan - Brunei Bisaya
Bisayan - Sabah Bisaya
Blackfoot
Bosnian
Bulgarian
Cambodian - Central Khmer
Cambodian - Northern Khmer
Cantonese
Carrier
Cayuga
Chilcotin
Chinese
Chippewa
Cree
Creoles
Croatian
Czech
Danish
Dari
Delaware
Do not know
Dogrib
Dutch
English
Estonian
Finnish
Flemish
French
Frisian
German
Gitksan
Greek
Gujarati
Hebrew
Hindi
Hungarian
Ilocano
Inuinnaqtun
Inuktitut
Italian
Japanese
Karen
Korean
Kurdish
Kutchin-Gwich'in (Loucheux)
Lao
Latvian
Lithuanian
Macedonian
Malay
Malayalam
Malecite
Maltese
Mandarin
Mennonimee
Mi'kmaq
Mohawk
Montagnais
Naskapi
Nepali
Nisga'a
North Slave (Hare)
Norwegian
Odawa
Ojibwa
Ojicree
Oneida
Other
Other Indigenous Language
Other Native Language
Pashto
Persian (Farsi)
Polish
Portuguese
Pottawatami
Prefer not to answer
Punjabi
Romanian
Russian
Seneca
Serbian
Serbo-Croatian
Shuswap
Sindhi
Sinhala
Siouan Languages (Dakota/Sioux)
Slovak
Slovenian
Somali
South Slave
Spanish
Swahili
Swedish
Tagalog (Pilipino, Filipino)
Taiwanese
Tamil
Telugu
Tigrinya
Tlingit
Turkish
Tuscarora
Ukrainian
Urdu
Vietnamese
Yiddish
Please include the area code with phone number.
You can provide additional details to the phone number provided in the adjacent comments box.
Home/Main Phone:
Permission to Call?
Yes
No
Leave a Message?
Yes
No
Comments:
Work Phone:
Permission to Call?
Yes
No
Leave a Message?
Yes
No
Comments:
Alternate Phone:
Permission to Call?
Yes
No
Leave a Message?
Yes
No
Comments:
Email Address:
Address:
:
City:
Province:
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland/Labrador
Nova Scotia
Ontario
Prince Edward Island
Quebec
Saskatchewan
Northwest Territories
Nunavut
Yukon Territory
Out of Country
Country:
Postal Code:
What is your mother tongue?
Akan
Algonquin
Amharic
Arabic
Armenian
ASL, (American Sign Language)
Athapaskan languages
Atikamekw
Bengali
Bisayan - Brunei Bisaya
Bisayan - Sabah Bisaya
Blackfoot
Bosnian
Bulgarian
Cambodian - Central Khmer
Cambodian - Northern Khmer
Cantonese
Carrier
Cayuga
Chilcotin
Chinese
Chippewa
Cree
Creoles
Croatian
Czech
Danish
Dari
Delaware
Do not know
Dogrib
Dutch
English
Estonian
Finnish
Flemish
French
Frisian
German
Gitksan
Greek
Gujarati
Hebrew
Hindi
Hungarian
Ilocano
Inuinnaqtun
Inuktitut
Italian
Japanese
Karen
Korean
Kurdish
Kutchin-Gwich'in (Loucheux)
Lao
Latvian
Lithuanian
Macedonian
Malay
Malayalam
Malecite
Maltese
Mandarin
Mennonimee
Mi'kmaq
Mohawk
Montagnais
Naskapi
Nepali
Nisga'a
North Slave (Hare)
Norwegian
Odawa
Ojibwa
Ojicree
Oneida
Other
Other Indigenous Language
Other Native Language
Pashto
Persian (Farsi)
Polish
Portuguese
Pottawatami
Prefer not to answer
Punjabi
Romanian
Russian
Seneca
Serbian
Serbo-Croatian
Shuswap
Sindhi
Sinhala
Siouan Languages (Dakota/Sioux)
Slovak
Slovenian
Somali
South Slave
Spanish
Swahili
Swedish
Tagalog (Pilipino, Filipino)
Taiwanese
Tamil
Telugu
Tigrinya
Tlingit
Turkish
Tuscarora
Ukrainian
Urdu
Vietnamese
Yiddish
If your mother tongue is neither English nor French, in which of Canada's official languages are you most comfortable?
English
French
Additional Information (Optional)
What is your marital status?
Common Law
Divorced
Do not know
Married
Other
Prefer not to answer
Separated
Significant Other
Single
Widowed
Do you have children at home?
No
Yes
If yes, how many?
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