Request for Services

Please see 'Fees' section for an important announcement about a change in our fees, effective September 2022

Client Name(Required)
MM slash DD slash YYYY
Address(Required)
May we email you?(Required)
Please note that email correspondence is not considered to be a confidential medium of communication.
Leave Message?(Required)

Source of Request

Name
If not self-request, is the client in agreement with the request?
Service Requested:(Required)
PLEASE NOTE:
Ruah staff member will be in contact with you within five (5) business days for appropriate follow up.
Ruah is not a crisis centre. If you require help immediately, please phone the Mental Health Crisis Line at: 1-888-737-4668 or go to your nearest Emergency Department.
This field is for validation purposes and should be left unchanged.