Family Services Ottawa
312 Parkdale Avenue
Ottawa  Ontario  K1Y 4X5


Phone: (613) 725-3601,
Fax: (613) 725-5651,
Email: info@familyservicesottawa.org
Referral Type:
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Referral:
ATR Program Intake Form ID
Date: 2025-11-21 07:24
Status: Draft
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Please take a moment to complete our program registration form. The demographic information helps guide us in our program planning and improve the quality of service. The information is kept confidential and is used in a way that does not identify you. You can choose not to answer any of the demographic questions, and it will not impact the care you will receive.

When completing the name section of this form, please tell us what name you go by.
Client Details
First Name
Last Name
Preferred Pronoun
Date of Birth
Select Date Clear Date
Gender Identity
Language Interpreter required
Additional Gender Identity Details
Intersex/Intergender
Trans Girl/Woman
Boy/Man
Non-Binary
Transgender
Trans Boy/Man
Trans/Non-Binary
Girl/Woman
Two-Spirit
Questioning/Exploring
I identify with another gender
Preferred Language
Client Contact Information
Phone (Home/Main)
Permission to call?
Phone (Home/Main)
Permission to leave a message?
Phone (Home/Main)
Permission to text?
Phone (Home/Main)
Email
Permission to contact via Email
Client Address Information
Address Line
City
Location/County
Postal Code
Province
Country
Referral Information
Reason(s) for the referral
Referral Source
Do you identify as any of the following communities?
Choose all that apply.
2SLGBTQI+
A person who is living with a disability (This may include cognitive, intellectual, physical, mental health)
Francophone
Newcomer (You were born in a country other than Canada)
Visible Minority
Prefer not to answer
Emergency Contact
Emergency Contact Name
Emergency Contact Relationship
Emergency Contact Phone Number
Emergency Contact Preferred Language
Additional information you would like us to know when calling your emergency contact:
Please select the group you (your child) will attend
Group
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