Self-Referral – Peer Support South East Ontario

Self-Referral for Peer Support

Providing intentional Peer Support throughout South East Ontario, without walls.

Please fill out the Self-Referral form and someone will contact you soon!

If you are thinking about suicide or in crisis, please call 988.

If this is an emergency, please call 911.

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First Name *

Last Name *

Date Of Birth *

YYYYMMDD

Sex *

Gender Identity

Unhoused/transitional/vicariously housed?

Street Address

Birth Telephone Date

City *

Email Address

Telephone Contact # *

###-###-####

Permission to Leave Message?

Preferred Language *

Identify As:

Living Arrangements *

Briefly, what support are you looking for today?

Peer Support South East Ontario

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Charitable Registration Number: 860860287RR0001