Please complete the following questionnaire to help us determine appropriate service options. All information is confidential and will only be shared with your selected clinic with your consent. Subsidy is available to residents of the Town of Strathmore, Village of Hussar, Village of Rockyford, Village of Standard and Wheatland County. 
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Your information is collected and stored securely in accordance with the Health Information Act (HIA) and the College of Alberta Psychologists’ Standards of Practice and the Alberta College of Social Workers (ACSW). Only authorized personnel involved in the referral process will have access to it. Completion of this form does not establish a social worker or psychologist–client relationship; a registered social worker or psychologist will review your information to determine suitability.
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