We want to acknowledge your courage and willingness in reaching out for help. By answering the questions in this form as fully as you can you’ve taken an important step towards getting that help! When you get to the bottom of each page, click NEXT until you reach the end. You will be asked to sign before you can submit. Thank you!
** Allow about 15-20 minutes
** Make sure to finish in one sitting, and SUBMIT at the end, or your info may be lost.
This information will be kept strictly confidential as per the Health Professions Act, Personal Information Protection Act, the requlations of each of the professional governing bodies for the professionals at Empower Health and Canadian law. Your personal information is collected for the purpose of providing health care and for administrative purposes. It will not be disclosed for other purposes without your consent other than for reasons stated in the laws.