Sister Strength Enrolment Form

Sister Strength Enrolment Form

Thank you for your interest in the Sister Strength program - a collaborative offering between the Canadian Legacy Project and HavenPoint Health. The information you provide below will be used by our team to contact you regarding your interest in the Sister Strength program. If you need assistance prior to that, please contact us at 902 332-3246 (Ext. 102 Shelley Cliche) or 1 888 861-8387.
Full Name*

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Date of Birth

MonthDayYear
Date
Veteran Service/ID #:
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Primary Healthcare Provider:

Family PhysicianNurse PractitionerNo Primary Care Provider
Primary Care Information

NameTelephone
Services you currently participate in:

AccupunctureConcussion CareChiropractor CareKinesiologyMassage TherapyMental Health TherapyNeurofeedbackPhysical TherapyOther
What is your preferred method of contact:
Please share any relevant medical history/diagnoses/disabilities with us:
Are you currently taking any medications?

YesNo
Please list any current medications.
Have you previously participated in any mental health counseling/therapy?

YesNo
Have you previously had a psychological assessment or been provided a mental health diagnosis?

YesNo
What are you hoping to experience through your participation in the Sister Strength program?
Please let us know your preferred time for weekly virtual, group sessions:

Morning (between 9:00 to 12:00 am EST)Afternoon (between 1:00 to 4:00 pm EST)Early Evening (between 4:00 to 7:00 pm EST)Other
Today's Date:

MonthDayYear
Date
Signature:

Powered by Jotform SignClear
Should be Empty: