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This Program/Service is provided by: Canadian Mental Health Association, Hastings and Prince Edward Branch
Key Info
Program/Service Name (English)
Acronym ()
Program/Service Name (French)
Acronym ()
Area Served (Catchment)
Additional Catchments (Optional - Admin Only)
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Description (English)
Description (French)
Website (English)
Website (French)
Public Email Address
Are there age criteria for services?
Yes    No
Intake Information (Optional)
Intake Procedure(s)
 Not provided
 Not applicable
 Clients/families may self refer
 Physician or professional referral is required
If applicable, provide additional intake criteria
Attach intake form
Location
Physical address not available or not applicable
Country
Street Number
Street Name
Unit/Suite/Apt.
PO Box
City
Province/State
Postal/Zip Code
Phone (eg: 555-555-5555 x345)
Toll free phone
Crisis phone
This Program/Service is typically delivered in the following settings
Other
Language & Fees
What languages are services provided in?
   English
   French
   Spanish
   Arabic
   Mandarin
   Cantonese
Any other languages?
Do you charge fees?
Description of fees (if applicable) English
Description of fees (if applicable) French
Who Do You Serve?
Do you have services that SPECIFICALLY target any of these Specific Groups?
Other
Select the Appropriate BestStart Network Category (if applicable)
If you provide services for aged 0-6, please indicate the relevant BestStart category.
Other
Which Conditions/Issues are addressed by this Organization?
Other
What Types of Services Do You Provide?
Can people (who are not already connected with your services) contact you to receive any of these Types of Services?
(Although you may offer any or all of these Types of Services to your clients, please DO NOT check off these services unless you provide them to the general public, or to those not yet connected to your services.)
Other
Can the general public contact your program/service for services from any of these Types of Professionals?
NOTE: For example, you may have Psychologists working at your agency, but if the general public cannot contact your agency specifically looking for Psychologists, then please do not indicate that you provide this service.
Other
Thank You for Helping Your Community!
Please tell us a bit about yourself (optional). This information will be used simply to contact you if we have further questions. It will not be published.
Your Name
Position
Phone
Email
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Comments or Suggestions?