Community Wellbeing/GIT Registration form

Jane/Finch Community and Family Centre Community Wellbeing Program

Client Registration form
Applicant Information
The Community Wellbeing Program supports residents of Jane and Finch and neighbouring areas by promoting mental health and overall wellbeing. The program, which serves anybody ages 13+, offers services delivered on a one-to-one or group basis.

For questions about the services we offer, please contact Community Wellbeing Program via email at cmh@janefinchcentre.org or via phone 416-663-2733 ext 217.
Client's name*

First NameMiddle NameLast Name
Date*

MonthDayYear
Date
Pronouns
Birth Date*

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Number*
Phone Number
Email*
example@example.com
Interpreter needed?

YesNo
If Yes, what language?
Program Information
Which Community Wellbeing Programs are you interested in joining?*

Service Navigation (Ages 13-29)Service Navigation (Ages 30-55)Service Navigation (Ages 55+)GIT Program (Ages 30-55) (Monday and Tuesday 1pm-3:30pm)GIT Connected (Ages 13-29)Seniors Program (Ages 55+) (Wednesday 12:30pm)Spanish Speaking Seniors Program Virtual (Thursday 1:00pm-3:00pm)
Reasons for joining Community Wellbeing Programs:
Emergency Contact Information

In the event of an emergency please contact:
Name: *
Relationship: *
Phone:*
How did you hear about the program?
How did you hear about the Program (Check all boxes that apply)

Jane/Finch CentreCommunity Mental Health TeamWord of mouthCommunity CentreSchoolHospital/Clinic/DoctorPoster/FlyerCommunity EventBlack Creek Community Health CentreSocial mediaOther
Other (please specify)
If you are a service provider referring a client, please fill out the section below
Name

First NameLast Name
Agency
Phone Number
Please enter a valid phone number.
Email
example@example.com
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Jane/Finch Community and Family Centre Community Wellbeing Program

Applicant Information

Program Information

Emergency Contact Information

How did you hear about the program?

If you are a service provider referring a client, please fill out the section below