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**ROFILE OF CAFCO IN IMAGE SANDY HILL – APRIL/MAY 2014 ISSUE**

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Request for Services

Initial Appointment Request - Children

Province which you reside *

City *

Service type *

Family Status *

-- Assessment --

-- Treatment --

-- Group Therapy--

Language *

Location *

Your name *

Client name (if different from above)

Client date of birth

Client school(if applicable)

Phone number with voicemail *

Email address *

Do you have insurance? *

Does your insurance cover: psychologist? *

Does your insurance cover: social worker? *

Does your insurance cover: speech-language pathologist? *

Referral Source *

Add Reason for referral/presenting problem *

Other requests or pertinent information?

By checking this box I hereby authorize the the Child, Adolescent, and Family Centre of Ottawa (CAFCO) to communicate with me via the means provided above regarding the services I am requesting. I also understand that CAFCO does NOT use email addresses or any other electronic addresses for commercial/promotional purposes as understood by Canada's Anti-Spam Legislaton (CASL).

Initial Appointment Request - Adolescents

Province which you reside *

City *

Service type *

Family Status *

-- Assessment --

-- Treatment --

-- Group Therapy--

Language *

Location *

Your name *

Client name (if different from above)

Client date of birth

Client school(if applicable)

Phone number with voicemail *

Email address *

Do you have insurance? *

Does your insurance cover: psychologist? *

Does your insurance cover: social worker? *

Does your insurance cover: speech-language pathologist? *

Referral Source *

Add Reason for referral/presenting problem *

Other requests or pertinent information?

By checking this box I hereby authorize the the Child, Adolescent, and Family Centre of Ottawa (CAFCO) to communicate with me via the means provided above regarding the services I am requesting. I also understand that CAFCO does NOT use email addresses or any other electronic addresses for commercial/promotional purposes as understood by Canada's Anti-Spam Legislaton (CASL).

Initial Appointment Request - Adults

Province which you reside *

City *

Service type *

-- Assessment --

-- Treatment --

-- Group Therapy--

Language *

Location *

Your name *

Client name (if different from above)

Client date of birth

Client school(if applicable)

Phone number with voicemail *

Email address *

Do you have insurance? *

Does your insurance cover: psychologist? *

Does your insurance cover: social worker? *

Does your insurance cover: speech-language pathologist? *

Referral Source *

Add Reason for referral/presenting problem *

Other requests or pertinent information?

By checking this box I hereby authorize the the Child, Adolescent, and Family Centre of Ottawa (CAFCO) to communicate with me via the means provided above regarding the services I am requesting. I also understand that CAFCO does NOT use email addresses or any other electronic addresses for commercial/promotional purposes as understood by Canada's Anti-Spam Legislaton (CASL).

Initial Appointment Request - Couples

Province which you reside *

City *

Language of help needed *

Location *

Your name *

Your partner’s name *

Phone number with voicemail *

Email address *

Do you have insurance? *

Does your insurance cover: psychologist? *

Does your insurance cover: social worker? *

Does your insurance cover: speech-language pathologist? *

Referral Source *

Add Reason for referral/presenting problem *

Other requests or pertinent information?

By checking this box I hereby authorize the the Child, Adolescent, and Family Centre of Ottawa (CAFCO) to communicate with me via the means provided above regarding the services I am requesting. I also understand that CAFCO does NOT use email addresses or any other electronic addresses for commercial/promotional purposes as understood by Canada's Anti-Spam Legislaton (CASL).