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Our Services
Client Application
Contact Us

Client Application Form

Instructions

Please complete the Client Application on this page as accurately as possible. Please note that it can take a few days to hear back from our team.

Once approved, you will be provided with next steps.

Learn more about:

Brief Counselling
Support Programs
Trainings
Workshops

Client Application Form

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SECTION 1: Referring Party Information

What kind of referral is this?

Self Referral

Organization Referral

Individual Referral

Name of Referring Individual/Organization

What is the relationship to the Client? Enter N/A for yourself

Referring Party Phone Number

Referring Party Email

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SECTION 2: Client Information

The information pertains to the individual that will be receiving the support.

Client First Name

Client Last Name

Client DoB

Client Phone Number

Client Email

Client Street Address

City

Province

Postal Code

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SECTION 3: Cultural Identity & Language

Cultural Identity

Nation/Band Affirmation (if applicable)

Preferred Language(s)

Do you need an interpreter?

Yes

No

Are there any Spiritual/Cultural practices you would like honoured in Services with Mend the Gap?

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SECTION 4: Safety & Accessibility

Accessibility Needs

Preferred meeting setting

Any immediate safety concerns

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SECTION 5: Reason for Referral

Services Requested (please select all that apply)

Mental Health Support

Addictions Support

Grief and Loss

Career Skill Building and Exploration

Life Skill Building

Housing or Shelter Support

Outreach Services (in-community)

CAST Program: Community Access Support Time (Drive Program)

Empowered Meals Program

Strong Foundations Program

Alongside You Program

Other (provide below)

Other Service (if applicable)

Description of Need

Thank you, we've received your Client Application Form!

We will be in touch with you soon.

Oops, there was an error with your submission.

Please try again later.

Mend the Gap Community Services Inc.

t: (825) 606-5504

e: info@mendthegapgp.com

10124 101 Avenue, Grande Prairie, Alberta T8V 0Y2, Canada

Explore

Brief Counselling
Support Programs
Trainings
Workshops
Client Application

Resources

9-8-8 Crisis Hotline
Alberta 211
Kids Help Phone

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We acknowledge that we work and gather on the ancestral and traditional lands of the Indigenous peoples of Treaty 8, who have stewarded this land for generations. We honor the histories, cultures, and ongoing contributions of the Cree, Dene, Inuit, Métis, and all First Nations who enrich our community.