Client Intake Form

This form allows you to request services from Centre Victoria pour femmes (CVF). This request form is open to any Francophone or French-speaking woman who has experienced, is experiencing, or is at risk of experiencing gender-based violence.

Please note that Centre Victoria pour femmes offers services on a voluntary basis and the person (client, survivor, etc.) requesting the service must be present to complete this form. Service providers can assist their clients in completing this form.

Centre Victoria pour femmes is committed to providing an initial response to this request within 5 business days. It is important to note that Centre Victoria pour femmes is not an emergency service and that services are closed on weekends and holidays. If you are in immediate danger, call the police, 911, or your community’s emergency services.

"*" indicates required fields

Personal Information

First Name*

Last Name*

Pronouns (e.g. she/her, they/them)*

Date of Birth*

City*

Why are you reaching out to our services today?*

Contact Information

Phone Number*

Is it safe for us to call you?*

Yes

No

Is it safe for us to leave a message?*

Yes

No

Email Address*

Is it safe for us to email you to confirm appointments?*

Yes

No

Confirmations

I confirm that I identify as a woman.*

Yes

I confirm that I would like to receive services in French.*

Yes