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Intake Form

Your Journey to Compassionate Support Starts Here

Our intake form is the first step in connecting you with our comprehensive range of services, tailored to support you and your family through every stage of your journey. Fill out the form below to help us understand your needs and how we can best support you. Together, we can build a community of care, compassion, and strength.

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African Refugee Crises Food & Health Program

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African Refugee Crises Food & Health Program

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African Refugee Crises Food & Health Program

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African Refugee Crises Food & Health Program

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African Refugee Crises Food & Health Program

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African Refugee Crises Food & Health Program

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African Refugee Crises Food & Health Program

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African Refugee Crises Food & Health Program

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African Refugee Crises Food & Health Program

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Hands Lifting Hearts Intake Form

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Name
Address
Marital Status
If Married/common law Are you in Canada with Spouse?
Are you pregnant?
If pregnant, are you having.
How long have you been in Canada?
What's Your Status?
How can we support you? (check all that apply)

Consent

In order to coordinate support, I give Hands Lifting Hearts my consent to share my information with other agencies provided it is deemed in my best interest.
Signed