Home
About Us
Services
- Children
- Adolescents
Resources
Contact

English

Request For Services

Group Services

For our current group offerings, please see our Resources – Upcoming Events tab above.

Join the CAFCO mailing list

Enter your email address to join the CAFCO mailing list and be the first to hear about what's going on

Home
About Us
Services
Resources
Contact
Privacy Policy

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).