Contact Service Navigator

1
Your Name* This field is required.
First Name
Last Name
2
Your Email* This field is required.
example@example.com
3
Your Phone Number* This field is required.
Area Code
Phone Number
4
Client's Name
First Name
Last Name
5
Client's Birth DateIf we know how old your child is we can make better recommendations on their service.
Date
Month
Day
Year
6
Current Date
Date
Month
Day
Year
7
Number
8
Client's diagnosisSelect all that apply
Autism spectrum disorder
Intellectual disabilities
Other
9
If you said other please explainLet us know what your area of interest is and we'll take that into consideration when sending you messages.
10
OAP Registration NumberYour Ontario Autism Program Registration will either start with OAP, KIN or CIS followed by dashes and numbers. If you are not yet registered for the OAP please leave this section blank.
Follow the formatting here OAP-000-0000.
11
MessageShare any information that will help us better serve you including programs you are interested in.
Huge
Large
Normal
Small
Ok
Ok
12
Schedule an appointment with our Service Navigator then hit NEXT in bottom right.Our service navigator can help you assess your service options and how to access those services. Re-enter your email so we can send you appropriate notifications via our scheduling system. You can also add the appointment to your personal calendar.
13
Referrer
14
15
Newsletter
Yes, subscribe me to this newsletter.
16
Disclosure* This field is required.We use software programs to collect and manage your information to provide services. We want to be transparent about that and ensure you know how your data is used. Your data is never provided to third parties for their use. (Privacy Policy)
I consent to the use of third-party software accessing my data including when necessary Personal Health Information (PHI), exclusively to provide me with information and services from Lake Ridge Community Support Services.
Should be Empty: