Champlain - Preliminary Screener

This pre-screener is a new initiative for Home and Community Care Support Services Champlain. We are always looking to improve - if you have any feedback about this form, please call 310-2222.

This pre-screener is intended for information purposes only. If you are in need of urgent medical attention, please call 911 or go to your nearest emergency department.

We aim to be in touch regarding your request within 2 business days. If you feel you require immediate service, or if you experience any difficulties completing the form, please call us directly at 310-2222 to discuss your needs with an intake team member.

This pre-screener only applies to people 18 years and above. If you are younger than 18 years old, or completing on behalf of someone younger than 18 years old, please contact Home and Community Care Support Services Champlain directly at 310-2222.

Thank you for making this request. Please select if you are making this request for your self or someone else and enter your contact information below.

Please note that if you are making this request on behalf of someone else, you will need their Health Card Number and date of birth to complete and submit the form.

Please use this box to provide any additional information you would like us to know; in particular, what sort of help you are looking for:

        I have reviewed the privacy consent policy (click here to review). *