All information collected from this form will be kept confidential with the Mental Health Crisis Line
Please check appropriate box:
(* all fields are required)
* Select which services you are concerned about (you may check both boxes):
* Select geographic area:
Prescott and Russell
Stormont, Dundas & Glengarry and Akwesasne
* Date and time (to the best of your ability) of the interaction:
* Specifics of the concern:
* Contact information:
Please enter contact information where you may be reached for follow-up. Our follow-up may include gathering more information to help us properly address your concern or to inform you of measures we are taking to improve the quality of our services as a result of your participation in this process.
Please answer this question to prove you're human:
This service is for individuals 16 years or older living in:
Click here for map and complete area listings.