REQUEST FOR A SERVICE – PROCEDURES

You are interested in participating in the Centre’s therapeutic services? You must make the request yourself, using the Online form, or by telephone.

1. Service Preferences (Waiting lists): You have the possibility of participating in one service at a time at the Centre. However, you may place your name on two (2) waiting lists. You can consult the various descriptions of our therapies online in order to help you make your choices. Please indicate your waiting list preferences on the online form.

2. Telephone questionnaire: Following the reception of your online request, a clinical worker from the Centre will contact you within two to four weeks, according to available human resources and the period of the year (vacation) in order to complete a questionnaire, by telephone (30 minutes). The goal of the questionnaire is to determine whether the services at the Centre correspond to your needs and to confirm your waiting list choices.

3. Message delays: A clinical worker will leave you a maximum of two messages and you have a maximum of two weeks to return their call. If the questionnaire is completed within a two week delay, the date of the request for a service shall be the date of your initial online request. However, if you do not return the call after two weeks, the date of the request for a service shall be the date of your returned call.

4. Additional Information: Other information on the Centre and its services shall be provided to you during the telephone interview.

ONLINE FORM

 IDENTIFICATION

Date of Request:


Age :  (18 to 65 years of age inclusively)    Prefix (Mr./Ms.). :     


First Name :


Last Name :


Address :


City :


Postal Code :


Telephone No. - Home :


Telephone No. - Cell :


Telephone No. - Other:


Can we leave a phone message at any of the given phone numbers?  If so, please indicate the number.    


Best time to reach you - AM (9am – 12noon)  PM (1pm - 5pm)  Other    


What is your language of preference? -  English or French    


Reference:  CLSC ,  Hospital,  Community Organization,  Other



Please indicate 2 of your Waiting List choices? 
 

Email :


Additional Comments :