African Community Services of Peel- Client Intake Form

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Please complete the ACS Client Intake form, detailing the services you are reaching to us about.

For any other questions or concerns, please reach out to us via the contact details below:

Email: info@africancommunityservices.com
Office Number: 905-460-9514
Alternative contacts: 647 570 9514 / 647 451 9514

Full Name *

Pronoun, (Example, she/her or he/him or them/they) *

Email Address *

Phone Number *

How would you prefer to be contacted *

Phone- Call

Phone- Text

Other:

Age Range *

15-20 years old

20-25 years old

25 - 30 years old

30 - 40

40 and up

Required

Address/ City/ Province/ Postal Code *

Language(s) Spoken: *

English

French

Other:

Please choose which Program you require from the list below: *

Please identify which Service you require from the following list: *

General Information

Advocacy Issues

Booking Intake Appointments

Child care/ Daycare Information

Contacting Government Offices

Counseling/Emotional Support

Educational/Skills Upgrading

Employment Related Services

ESL/LINC Information

Health/Medical/OHIP

Housing/Tenancy Issues

Immigration/Refugee/Citizenship

Legal Matters

Referral to Services

Request for Interpretation Services

Translation of Documents

Other

Comments:

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