GRANT APPLICATION

Please take a moment to fill out this application for our Safe & Sound Program (SSP). We thank all referrers and applicants for your interest and support of this program.

Last Name

First Name

Street Address, Suite #, Apt #, Box #

City / Town

Province

Postal Code

Country

Email address

Please provide at least one phone number. Your mobile number can be used to look up your account and receive text message appointment reminders

Mobile Phone

Home Phone

Work Phone

Date of Birth

Gender

Refers to current gender which may be different than what is indicated on your insurance policies

Guardian

Emergency Contact

Emergency Contact Phone

Emergency Contact Relationship

Name of Referring Professional

Referring Professional Phone or Email (if known)

How did you hear about us ?

Friend

School

Physician / Specialist

Online Ad

Web Search

Other

Occupation

Employer

How many people live in your household? Who?

Please tell us about why you/the person you are applying for are interested in completing the SSP program?

Please tell us about why you're applying for this grant? What Behaviours/challenges are present?

Thank you. Your application will be confidentially reviewed by a committee of Clarity Clinic Team Members

Your information will be encrypted.