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Group Information

*Name of Support or Self-Help Group:

Name of Sponsoring Organization (where applicable):

*Group Contact/Facilitator (This may be a different contact person than above) :

*Street Address :

*City : --Select one-- Brampton Burlington Kitchener London Ottawa Scarborough Toronto Other      OR    Other City :

*Province :      *Postal Code :

Email :

Web site :

*We are a:
--Select one-- Support Group Self-Help Group Other
Other:

*We are a group for:
--Select one-- Addiction Anorexia Anxiety Disorders Asperger Syndrome Attention Deficit Disorders Autism Bipolar Disorder Bulimia Depression Eating Disorders Mood Disorders Obsessive Compulsive Disorder Phobias and Panic Disorders Psychosis Schizophrenia Seasonal Affective Disorder (SAD) Self Harm Suicide Other
Other:

Our group includes or is moderated by a Mental Health Professional:
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Please tell us about your group :
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