Allied Against Abuse.
24-Hour Support Line (905) 356-5800

Men’s Support Services Intake Form

Please use the form below to connect with Birchway Niagara’s Men’s Intake Worker. They will respond within seven business days.

If you are in immediate danger, please contact 9-1-1. You can also access immediate support using the following services:

Participant Information

We'll need the participant's legal name.
This field is required.
What's the participant's date of birth?
This field is required.
This field is required.
What's the participant's address?
What city or town do they live in?
What's their postal code?
What number can we reach them at?
What email address can we use?

Safe Contact

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What Brings You to the Program?

Please select at least one option.
Check all that apply.
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Intake Information

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Please select at least one option.
This field is required.

Consent

Birchway Niagara keeps the information on this form confidential. Only staff who need it to respond to this referral can see it, and we use it only to connect the participant with Men’s Support Services. We’ll ask for consent before sharing it for any other purpose, except when we’re required to report. We have a legal and ethical obligation to report to FACS Niagara on issues related to children who are exposed to abuse, or if someone intends to harm themselves or others. Send privacy questions to info@birchway.ca or read our privacy policy.

Please check this option.
If you're completing this form on someone's behalf, check this box only after they've agreed.
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