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Service Request Form
Service Partners Only:   

CONTACT NIAGARA is committed to protecting your privacy and confidentiality. Our committment is articulated in our Privacy Statement.

Please provide the following information and select the SUBMIT button below. Your information will be used to provide assistance in identifying local resources, and / or starting the intake process for MCSS/MCYS programs. A Resource Coordinator will attempt to contact you within one business day. Your information will be electronically stored and protected by CONTACT NIAGARA until we have made contact with you. If no intake is complete, your identifying information will be destroyed.

PLEASE NOTE:
CONTACT NIAGARA is committed to protecting your privacy, taking every step possible to ensure that your information remains confidential, and is only used for the purpose stated above. The nature of the Internet and email limits CONTACT NIAGARA's ability to protect your information on these systems. We suggest you use discretion with the amount of specific details you provide on this form, and not include names (other than your own). If there are concerns regarding the security of the information you wish to share, we suggest that you do not complete this form, but contact us by phone (905-684-3407, 1-800-933-3617) between the hours of 8:30 am and 4:30 pm weekdays (excluding Statutory Holidays).

CONTACT NIAGARA On-Line Service Request Form
Your Name (first & last): [REQUIRED]
Your relationship to the individual:
Agency (if any):
Phone number, daytime: [REQUIRED]
Phone number, evening:
Email:  [REQUIRED]
Best time to contact:
Best day to contact:
Please indicate if your request is related to:
A Child / Youth (Under 18 years) experiencing behaviour or emotional difficulty
An Individual (of any age) where developmental disability is suspected
 
Briefly describe your request:
 
Please Note: By submitting this form, you are giving CONTACT NIAGARA permission to collect and store this information until you can be contacted. The information will be destroyed if it is not required.
     

 
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Contact Niagara
23 Hannover Drive, Unit 8, St. Catharines, ON L2W 1A3
Toll Free: 1-800-933-3617  •   Tel: 905-684-3407  •   Fax: 905-684-2728  •   TTY: 905-684-6289
E-mail: info@contactniagara.org

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