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Request for Services

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

Client Name(Required)

First Last

Date of Birth(Required)

MM slash DD slash YYYY

Gender (Self identify)(Required)

Address(Required)

Street Address Address Line 2 City Province Postal Code

May we email you?(Required)

Please note that email correspondence is not considered to be a confidential medium of communication.

Yes

Best Telephone #(Required)

Leave Message?(Required)

Yes

Source of Request

Self OR Name and Address of Agency.(Required)

Name

First Name Last Name

Telephone # of Source

If not self-request, is the client in agreement with the request?

Yes

Service Requested:(Required)

Individual Counselling

Couple Counselling

Family Counselling

Group

If Group, indicate name of group

How did you become aware of our services?(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.

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Phone

This field is for validation purposes and should be left unchanged.