Call WCC: 519-669-8651 | Waterloo Region 24/7 Crisis Line: 1-844-437-3247

Contact Information

65 Memorial Ave, Elmira, Ontario N3B 2R9

Phone: 519-669-8651
Fax: 519-669-0980

Pre-Enrollment Form

We are glad you are reaching out to us and look forward to connecting with you.

If you are in crisis, feeling unsafe, or worried you might hurt yourself or others, contact Here 24/7 at 1.844.437.3247 or visit the nearest hospital emergency room. For emergencies, call 911.

Please use the form below to provide the information of the individual to be contacted.

Once you submit the form, we will contact you at the earliest possible time to determine how we can support you. Please be aware that our office is open Monday to Thursday with varying hours.

Only submit one copy of this form, even if completing for multiple individuals.

All information submitted will be kept confidential.

    Please enter your full name.

    Please enter your phone number.


    Please select either 'Yes' or 'No'

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    I consent.

    SelfCoupleFamilyChild(ren) - Ages 4-12Youth - Ages 12-18Group ProgramsWorkshop InformationYour client or referral

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    Additional Group Programs Information

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    Additional Workshop Information

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    Additional Client or Referral Information

    Please enter the name of the referrer

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    Please select either 'Yes' or 'No'

    A copy of client consent to be faxed to: 519-669-0980