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East Parry Sound Community Support Services
Did you know that you can self-refer for our services or that you can refer someone to us? Fill out a form to let us know and we will reach out!
Client Referral Form
First name
*
Last name
*
Address
*
Phone
*
Are you over or under 65 years of age?
*
Over
Under
What service(s) are you interested in?
*
Meal Delivery
Transportation
Seniors Luncheons
Falls Prevention Classes
Are you referring yourself?
*
Yes (I am requesting services for myself)
No (I am referring someone else)
If referring someone else:
(only if “No” is selected)
Additional Comments:
Submit
Contact Us
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