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Have you been affected by Intimate Partner Violence?
Referral form
Fields marked with an asterisk (*) are required.
First Name *
Email address or Phone Number *
Referral Source *
Self-Referral
Other
If other, please mention your referral source with their name and contact information.
Please review the eligibility criteria, and only proceed if you confirm *
I confirm that I or the participant I am referring is 18+ years of age, living in or near Simcoe/Muskoka, Ontario, and engaged in and/or experienced IPV in a romantic relationship within the last two years that lasted at least three months).
Thank you! Your submission has been received!
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