Request for Services Application

Background
Type of Service Requested: Day Services
- Employment
- Life Skills Training
- Recreation/Leisure
- Other
Other
Please specify.
Type of Service Requested: Residential
- Apartment
- Family Placement
- Group Home
- Respite Care
- Other
Other
Please specify.
Personal Information
Name*
First Last
Address*
Street Address Address Line 2 City Province Postal Code
Phone*
Date of Birth*
MM slash DD slash YYYY
Social Insurance #*
Health Card #*
Next of Kin/Guardian*
Advocate*
Relationship to Applicant*
Phone*
Referral Agent (if applicable)
Referral Agent's Phone
DSP Worker
Phone
Education
Last School Attended*
Date of Attendance*
MM slash DD slash YYYY
Last Level Reached*
Reason for Leaving*
Medical Information
General Health*
- Good
- Fair
- Poor
Family Doctor*
Physical Disability*
- Yes
- No
Please specify*
Medication*
- Yes
- No
Specify Type and Dosage*
Describe any other medical concerns
Please comment on any additional information
Name of person completing this application*
Email or Phone of person completing this application*
Whichever is your preferred method of communication.

CONTACT
701 Water Street West
Summerside
Prince Edward Island
Canada C1N 1E2

PHONE: (902) 436-7576

Background