Application for Services Application for Services Step 1 of 5 - Personal Information 0% Name* First Middle Last PronounAddress Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone*Cell/AlternateEmail Date of Birth* Date Format: MM slash DD slash YYYY Identified Gender:Preferred Language*EnglishFrench Service RequestPlease indicate the service(s) you are applying for: Mental Health Counselling (Case Management) Community Mentorship (Independent Living Skills Development) Employment Services (Career Coaching Employment Counselling) Seneca Respite (Peer-Supported, 5-Night Stays) Health InformationPlease indicate your Mental Health Diagnosis:Please indicate any concurrent diagnosis or developmental disorderAutism 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/OrganizationAddress Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code PhoneFaxEmail Referral SourceWho referred you to Sara Riel Inc.? Name Title Organization 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.CAPTCHAUntitled
