Online Booking Request Form

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, contact information, and referral source, 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 check your spam folder for an email from Cristina.Stanger@wrfn.info).

Availability: Cristina is currently working remotely and can schedule appointments (online or by phone) Monday through Friday, day or evening, with advanced notice.

Please note: meetings are a maximum of 50 minutes long

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:

Email:

Phone number:

Have you accessed any WRFN services or events in the past? (yes or no)

Your city of residence:

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

Myself

Parent/Guardian

Other family member (eg. grandparent, sibling, cousin)

Professional support or Service provider

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* 4. First name and age of person(s) with exceptionality:

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* 5. Please list relevant diagnostic information:

Formal diagnoses that have been given:

Suspected diagnoses:

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* 6. Is this diagnosis accepted by the individual?

Yes

Uncertain

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

Yes

Uncertain

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

3+ (this may require special arrangements)

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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?

WRFN Family Resource Coach (Erin or Sue F.)

WRFN website

WRFN newsletter

Recommended by a professional

Recommended by a friend or family member

Uncertain

Other (please specify)