SUMMARY OF INITIAL CONTACT

							                  SUMMARY OF INITIAL CONTACT

Method of Contact:        Drop In      Phone Call         Mailed Informtion     Other Referral

Name:                                       Date of Birth:


Local

Address:

Postal Code:                        Phone #:

Home

Address:

Postal Code:                        Phone #:


E-mail:

Faculty:                             Program:                               Year:

Program Type:   Co-op   Regular            Distance Ed.
OSAP/OSBP eligible:   YES    NO

Referred from:                                 Referred to:


Documentation:
Disability and/or Accommodations:




Staff Initials:                                                     Date:



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