CMHRT Prospective Client Information Form

Interested in services at the Centre for Mental Health Research and Treatment (CMHRT)?

Please fill out the following information and we will contact you within three business days for further information.


Information and privacy: questions regarding the collection of information on this form can be directed to the form administrator.

Please provide your first name/given name.
Please provide your last name/surname.
Date of birth * (required)
Please provide a phone number where you can be contacted. (Please use the format XXX-XXX-XXXX, and include an extension if applicable.)
What is the best way to reach you? * (required)
Is it okay to leave a message? * (required)
Who are you requesting services for? * (required)
Child's birth date * (required)