Service Request

If you are interested in enrolling your loved one in our K.C.S.-ENRICH program, please enter your responses below and submit your request.

Date of Request:

Client Prospect (person to receive the service):

Type of Dwelling:

Area of Winnipeg:
 South North East West Downtown

*My Name (first and last):

My Title and Place of Work (if applicable):

My Relationship to Prospective Client:

My Phone Number:

*My Email:

My Address:

*I would like you to (choose one):
 1. Send me a contract to review. 2. **Send me all the necessary forms to initiate service, ie., the contract, life story questionnaire and assessment forms. Also set up an appointment to initiate service. Confirm the appointment time with me. I will bring the completed forms with me to the appointment. If I am not sure of some answers I will leave the information out and discuss it at our appointment. 3. Phone me to discuss this program further. We provide a free one hour phone consultation.

**If you selected #2 above, please enter your preferred days and times for an appointment to meet with you and the prospective client at his/her own residence below:

*If necessary, place my loved one’s name on a waiting list for this service and advise me:
 Yes No

Please note that service availability is guaranteed only upon the signing of a contract, in person, by appointment with Kennedy Cognitive Services, Inc.

Notes: