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.Format: (000) 000-0000.
Date of Birth

MonthDayYear
Date
Veteran Service/ID #:
Home Address

Street Address

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

NameTelephone
Services you currently participate in:

Other
What is your preferred method of contact:
Please share any relevant medical history/diagnoses/disabilities with us:
Are you currently taking any medications?
Please list any current medications.
Have you previously participated in any mental health counseling/therapy?
Have you previously had a psychological assessment or been provided a mental health diagnosis?
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:

Other
Today's Date:

MonthDayYear
Date
Signature:
Should be Empty: