Open Group Intake Form

For all programs, groups and services at Grand River Community Health Centre, we collect information about our group participants and clients. The info collected on this form will also help us to provide you with the best experience possible at GRCHC!

Please indicate the name of the group/ program you are registering for:

First & Last Name:

Preferred Name:

Birth Date:

Address & Postal Code:

Phone #:

Email Address:

Please provide the information for an emergency contact (Name, Phone Number, Relationship).

Social Information

Some social information is collected to help us better understand client needs and to improve our programs. If there is a question you would rather not answer, we provide a "prefer not to answer" option!

If NO, what country were you born in?

If NO, when did you arrive in Canada?

How many people does this household income support?