Ask A Self-Adovacate Program

Thank you for your interest in the Ask A Self-Advocate Program, a program run through the Waterloo Region Family Network. Please take a moment to complete this booking request form. Aside from your name and contact information, all other fields are optional, but by completing them it will help Cristina, our Self-advocacy Liaison, better meet your needs. You will be contacted within 5 business days to schedule a meeting time.

Please note: meetings are a maximum of 50 minutes long
Office hours: Mondays (typically, noon and 1pm appointment times at the Family Centre in Kitchener)

This is not a professional counselling service, but rather an informal discussion rooted in Cristina’s lived experience as an individual with exceptionalities.

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* 1. Name (First & Last):

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* 2. Contact information:

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* 3. Relationship to person(s) with exceptionality:

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* 4. Age of person(s) with exceptionality:

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* 5. Please list relevant diagnostic information:

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* 6. Is this diagnosis accepted by the individual?

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* 7. Is this diagnosis accepted by the individual's family members?

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* 8. Number of people who wish to attend the meeting with Cristina:

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* 9. The topics or issues I most wish to discuss are:

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* 10. How did you hear about the Ask A Self-Advocate Program?

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