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).

Please note: meetings are a maximum of 50 minutes long
Office hours: Mondays 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. First name and 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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