Centre Franco

Welcome to Centre Francophone du Grand Toronto!

Are you a member of the francophone community? Do you need services in French? Centre francophone du Grand Toronto (CFGT) offers a multitude of health and social services in French to francophone clients. Once you submit your application form, we will get back to you as soon as possible.

If you are experiencing difficulty in filling out this form, you can contact us at (416)-922-2672 at extension 8, or by e-mail at ac.contact@centrefranco.org

Thank you for choosing the CFGT!

Are you a :

Service provider New or existing CFGT client CFGT employee

Name of Service Provider :*

Contact Name :*

Contact Email :*

Telephone :*

Department

How did you find out about us?

If other, please provide details (For service providers, please indicate which services are being requested for your client)

I am requesting services for:*

Myself and one or more members of my family (or for your client and one or more members of the family) One or more members of my family (or one or more members of your client’s family) For myself only (or for my client only)

Are you an existing client (or are you making a referral for an existing client of CFGT)*

Yes No

Welcome to Centre Francophone du Grand Toronto!

Are you a member of the francophone community? Do you need services in French? Centre francophone du Grand Toronto (CFGT) offers a multitude of health and social services in French to francophone clients. Once you submit your application form, we will get back to you as soon as possible.

If you are experiencing difficulty in filling out this form, you can contact us at 416 922 2672, or by e-mail at ac.contact@centrefranco.org

Thank you for choosing the CFGT!

Centre Francophone du Grand Toronto | Services Referral Form

Name :*

Family Name :*

Telephone :

Telephone :*

Email address :

Email address :*

Preferred method of contact :

Telephone Email

Postal Code

Birth date

Status in Canada

North American Indian Canadian Asking for asylum Immigrant / Permanent Resident Work Visa Permit PVT Refugee Temporary Resident Other

Other

Dependants

Reason for Referral

Please indicate which services you wish to receive

Other services *

Other services

Please indicate which services you wish to receive and which services you have received

Other services *

Other services

Personal Information

First name :*

Last name :*

Birth date :*

Home Address

Address :*

Apt :

City :*

Postal code :*

Are you currently homeless?

Yes No

Email

Email*

Would you like to receive information about our programs and services by email?

Yes No

Contact information

Primary telephone number

Primary telephone number*

Secondary telephone number

Additional telephone number

Can we leave you a message?

Yes No

Health card

Do you have an Ontario Health Insurance Plan card?

number*

:*

Status in Canada

Canadian Indigenous Immigrant / Permanent resident Temporary resident Refugee Work Visa permit (WVP) Asylum seeker Other

Other

Country of origin

Date of arrival in Canada

Date of arrival in the

Socio-demographic Information

Gender Identity :

Sexual orientation :

Ethnicity :

Ethnicity, if other

Spoken language:

Language, if other

Revenue :

Number of Dependents :

Do you feel that your safety or that of a family member is at risk (physically, psychologically, nutritionally, emotionally, financially, spiritually, sexually)?

Yes No

Add another family member :

First name :*

Last name :*

Relationship :*

Birth date :*

Telephone :

Email :*

Date of arrival in Canada

Do you feel that your safety or that of a member of your family is compromised (physical, psychological, nutritional, emotional, financial, spiritual, sexual, safety)?

Yes No

Hi [first_name] [last_name]! According to Ontario law your family member can consent to the services of Centre Francophone du Grand Toronto. An application form will be sent to the email address provided. They will be able to choose the service(s) according to their needs and submit their request by themselves. Thank you for your confidence!

Other services

Other services *

Client consent :

In accordance with the Personal Information Protection and Electronic Documents Act PIPEDA and the Ontario Health Information Protection Act, the Centre Francophone du Grand Toronto is committed to protecting the confidentiality of any personal information you disclose.

At the Centre Francophone du Grand Toronto, Ms. Aissa Nauthoo, Vice President, Legal Aid, Settlement, Employment and Housing is the contact person for legal and confidentiality issues.

For more information regarding the privacy policies as well as your rights and responsibilities regarding personal information, please refer to our Public statement on the protection of personal information, or the laws shared above.