Intake Appointment Request Form
If you are interested in doing an intake please complete and submit the following form. Please note your information will be kept confidential. If you would like more information about this please email us at connect@stellasplace.ca or call us at 416-461-2345.
First Name *
Last Name *
Date of Birth *
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/
DD
/
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Phone Number *
For the phone number provided above please check off methods that are okay to use when contacting you at this number *
Required
What is your availability for an intake call? *
Email Address *
For the email address provided above please check off which of the following are okay *
Required
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