Date of Request:

Client Prospect (person to receive the service):

Type of Dwelling:

Area:
 South Winnipeg North Winnipeg East Winnipeg West Winnipeg Downtown Winnipeg Brandon & surrounding area

*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. Phone me to discuss this program further. We provide a free one-hour phone consultation.

*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: