GBV Intake Form

Information provided on this form will remain within the boundaries of the Canadian Council of Muslim Women for the purpose of identifying, guiding, and linking you to the services that you may need.

If you would like to contact someone from our team, please email [email protected] or contact us by phone at (647) 622-2221.

* Required Fields

GBV CLIENT INTAKE FORM

First Name

Last Name

Gender

Personal pronouns

Ethnicity

DOB (mm/dd/yyy)

First language

Translator services needed

Contact Information

City

Province

Cell Phone

Is it safe to leave a message at this #?

Is it safe to email this address?

Are there any instructions we should follow when contacting you by email or phone?

Needs Assessment

If you are in immediate danger or fear for your safety, please call 911. Assaulted Women’s Helpline (1-866-863-0511) is available 24 hours, 7 days a week for telephone support and referral information.

What service(s) are you currently looking to receive through CCMW’s Gender-Based Violence Program? Please select all that apply:

Medical/Health Services

Psychosocial/Counselling Services

Legal Assistance Services

Safe house/Shelter

Other (please specify)

Do you currently have legal aid?

Do you require financial assistance?

Would you like to speak to us for another reason? Please describe it here:

How did you hear about our organization?

Privacy Policy
Information provided on this form will remain within the boundaries of the Canadian Council of Muslim Women. No information will be released or shared without your signed consent. (Please keep in mind that such information may be requested by the legal team representing you.)
1. Someone from our gender-based violence team will be in touch with you periodically to provide relevant updates
2. We may follow up with your service provider to ensure you have received or are receiving assistance
3. Enrolment in our gender-based violence program is not a guarantee that your matter will be resolved. Our goal is to ensure women and girls in need or distress, receive effective help. Each matter is handled on a case-by-case basis.

Information provided on this form will remain within the boundaries of the Canadian Council of Muslim Women. No information will be released or shared without your signed consent. Please read the privacy policy and then sign here: