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 - New ID
Date: 2026-07-05 07:57
Status: Draft
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Hide/ShowParticipant Information:

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.

Parents/Caregivers: If more than one parent or caregiver is participating, we kindly ask each adult to fill out their own form.

When completing the name section of this form, please tell us what name you go by.
Participant Details
What first name do you go by?
Last Name
Pronoun
Date of Birth
Select Date Clear Date
Gender Identity
I identify with another gender
Language
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
Emergency Contact:
What is your relationship to the emergency contact person?
Contact Name
Emergency Contact Preferred Language
Can we list this person as your primary emergency contact?
Main Phone
Additional information you would like us to know about your emergency contact.
Do we have permission to call?
Do we have permission to leave a message?
Referral Source
How did you hear about the Around the Rainbow Program?
Reason(s) for the referral
Referral Source
Hide/ShowDo you identify as a member of any of the following communities?
Please feel free to leave these blank if you do not wish to answer:
2SLGBTQI+
First Nations / Métis / Inuit
Visible Minority or Newcomer (born in a country other than Canada)
A person living with a disability? (This may include cognitive, intellectual, physical, mental health.)
Hide/ShowProgram Participation
Please let us know which program(s) you want to participant in:
Parent/Caregiver Group All Ages
Centre 33 Parent/Caregiver Group
Transcend Youth Group
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