Please complete this short survey before your phone intake appointment. All the information collected in this survey is confidential and will be kept private.

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* 1. Name

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* 2. Email

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* 3. Date of birth

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* 4. Were you born in Canada?

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* 5. If no, where were you born and what year did you arrive in Canada?

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* 6. What is your highest level of education (completed or in progress - you can answer "prefer not to say")

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* 7. How did you hear of Totally outRIGHT?

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* 8. I am available on May 18th, 25th, June 1st, & 8th?

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* 9. If no, which date are you unavailable?

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* 10. Transportation needs

ACT can provide TTC tokens, GO Transit presto cards or Parking fees to participant. Please let us know what your transportation needs are:

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* 11. If you use GO transit, let us know your trip so we can calculate the cost:

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