Kerry's Place Autism Services
17345 Leslie Street, Suite 200
Newmarket Ontario L3Y 0A4
Phone: (833) 775-3779
Self-Referral
Please tell us how we can help you:
Please tell us who you are
* First Name:
Middle Name:
Last Name:
Preferred Name:
Date of Birth:
Age:
Gender:
Do not know
Female
Gender Non-Conforming
Intersex
Male
Non-Binary
Other
Prefer not to answer
Trans / Transgender - Female to Male
Trans / Transgender - Male to Female
Two-Spirit
Please tell us how we can contact you
Preferred Language:
Afrikaans
Arabic
Armenian
ASL, (American Sign Language)
Bengali
Bosnian
Cambodian - Central Khmer
Cambodian - Northern Khmer
Cantonese
Croatian
Dari
Dutch
English
French
German
Greek
Gujarati
Hausa
Hindi
Hungarian
Italian
Japanese
Kachi
Karen
Korean
Malay
Malayalam
Mandarin
Nepali
Other Indigenous Language
Persian (Farsi)
Polish
Portuguese
Punjabi
Romanian
Russian
Serbian
Somali
Spanish
Tagalog (Pilipino, Filipino)
Tamil
Twi
Ukrainian
Urdu
Vietnamese
Please include the area code with phone number.
You can provide additional details to the phone number provided in the adjacent comments box.
Home/Main Phone:
Permission to Call?
Yes
No
Leave a Message?
Yes
No
Comments:
Alternate Phone:
Permission to Call?
Yes
No
Leave a Message?
Yes
No
Comments:
Email Address:
Address:
:
City:
Province:
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland/Labrador
Nova Scotia
Ontario
Prince Edward Island
Quebec
Saskatchewan
Northwest Territories
Nunavut
Yukon Territory
Out of Country
Country:
Postal Code:
What is your mother tongue?
Afrikaans
Arabic
Armenian
ASL, (American Sign Language)
Bengali
Bosnian
Cambodian - Central Khmer
Cambodian - Northern Khmer
Cantonese
Croatian
Dari
Dutch
English
French
German
Greek
Gujarati
Hausa
Hindi
Hungarian
Italian
Japanese
Kachi
Karen
Korean
Malay
Malayalam
Mandarin
Nepali
Other Indigenous Language
Persian (Farsi)
Polish
Portuguese
Punjabi
Romanian
Russian
Serbian
Somali
Spanish
Tagalog (Pilipino, Filipino)
Tamil
Twi
Ukrainian
Urdu
Vietnamese
If your mother tongue is neither English nor French, in which of Canada's official languages are you most comfortable?
English
French
Attachments
Select File(s):
*
By sending this form, I allow the agency to contact me.
Send
All information is protected under Ontario privacy legislation and is kept confidential.