First Name
Last Name
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:
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
Are you registering as an individual or a supporting family member? Individual Supporting Family Member
What is your preferred language? English French
Address
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
Phone Number
