Health Assistance

Health Assistance Request (Non-Emergency)

Name of person needing support *

Age Group *
Youth (12–17)Adult (18–64)Senior (65+)

Type of support needed *
General health and wellness resourcesSeniors support / daily livingCaregiver supportMental wellness / community supportsCommunity health programsI am not sure – please guide me

City / Area *

Preferred language

Email *

Phone Number *

Best time to contact
Weekday - MorningWeekday - AfternoonWeekday - EveningWeekend - MorningWeekend - AfternoonWeekend - Evening

Brief description of the situation (non-emergency) *

Acknowledgement *
I understand this form is not for emergencies and consent to being contacted with community support information.