Feedback: Concerns

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):

Crisis Line
Local Crisis Team

* Select geographic area:

Prescott and Russell
Renfrew County
Stormont, Dundas & Glengarry and Akwesasne

* Date and time (to the best of your ability) of the interaction:

Day: Month: Year: Time:
eg. 8:30 

* 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.

First Name*Last Name*
*Required information. Feedback form will not be accepted without required information.

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