SIL Eastern Zone Care Request Form

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Filling out this form will help us connect you with the right care specialist or referral source. The only person with access to your completed form is the Area Psychologist, unless you specify otherwise. Your information will not be shared without your permission.

Name *

Role and unit of assignment

Preferred email *

Phone number (if you prefer to be called)

What concerns would you like to receive support for? *

How distressing are these concerns to you currently? *

Not at all distressed

Extremely distressed

Next steps *

Please share my information with the relevant care provider and have them contact me.

Please have the appropriate care provider contact me BUT do not share any information besides my name and contact details.

Please give me more information about who I can meet with, and I will contact them myself.

Location for next three months

Anything else you would like us to know

Limits to Care

Care provision is limited to availability of staff care personnel, location of the person requesting care and type of request. When care cannot be provided by the Area, referrals will be made to the best of our ability. Note regarding confidentiality: only services from a licensed therapist includes strict confidentiality.

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