ONLINE INTAKE

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Intake Form

You can also do an intake in-person:

2-443 Ouellette Ave

Windsor, ON N9A 4J2

Or you can do an intake by phone:

519-256-7831

First Name

Last Name

Phone

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Country

Date of Birth

Primary Source of Income

OW - Ontario Works

ODSP - Ontario Disability Support Program

OAS & GIS - Old Age Security & Guaranteed Income Supplement

CPP - Canada Pension Plan

War Veterans Allowance

WSIB - Workplace Safety and Insurance Board Benefits

Other - Please Specify Below

If you selected "Other," please specify the source of income (employment, Employment Insurance, self-employment, etc.) and what your estimated gross annual income is.

What do you need help with?

Ontario Works or Ontario Disability Support Program

Housing or Landlord/Tenant Law

Immigration

Gender-Based Violence & Sexual Assault

Other

Are there any deadlines we should know about (ex. hearing date, date you need to file by, etc.)? List them here.

Please provide a short description of what you need help with.

Please list any documents you CURRENTLY HAVE that are relevant to your issue.

How would you describe your race or ethnicity? (This question is optional and is asked for statistical purposes. It will not affect the assistance we provide you.)

How would you describe your gender? (This question is optional and is asked for statistical purposes. It will not affect the assistance we provide you.)

Thanks for submitting!

You can reach us at/ Vous pouvez nous joindre à:

2-443 Ouellette Ave.

Windsor, ON

N9A 4J2

Tel: 519-256-7831

Fax: 519-256-1387

TTY: 519-256-5287

Hours / Heures

Monday – Friday / Lundi – Vendredi

9:00am-4:00pm

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