First Name
Last Name
Address
Phone
Is it okay to leave a phone message? Yes No
Email
How do you identify your cultural background? This information will increase our awareness of specific cultural concerns and practices, and help us identify who we are reaching with this program.
Indigenous African Nova Scotian Caucasian Francophone New immigrant Other:
The person with a mental health/addiction problem or illness is your: Child Parent Sibling Spouse/Partner Friend Other:
Age of the person you are supporting Under 12 12-18 19-30 31-40 41-50 51-60 61+
What is the mental health/addiction problem or illness? Please check all that apply: Psychosis Schizophrenia Schizo-affective disorder Drug/alcohol addiction/gambling or gaming Bipolar disorder Depression Anxiety Disorder Obsessive Compulsive Disorder Personality disorder Undiagnosed Other:
How did you hear about this program? Poster Internet Community Health Team Family Doctor Mental Health Professional Friend Family Member Community Organization Other:
Do you consent to being contacted within the next 12 months for a follow up evaluation? Yes No
What is your preferred language? English French
City/Community
Which zone do you live in? == choose one == Central (HRM, Eastern Shore & West Hants) Eastern (Cape Breton, Guysborough & Antigonish) Northern (Colchester-East Hants, Cumberland & Pictou) Western (Annapolis Valley, South Shore & South West)
If you dont know your zone please refer to the link below. Please Click Here
