Membership Form

First Name:

Last Name:

Address:

City:

Province:

Postal Code:

Phone:

Date of Birth (optional):


Emergency Contact:

Emergency Phone Number:

Age: 16-2425-3435-4445-5455-6465+

Preferred Language: EnglishFrench

Are you a new member? YesNo

How long have you been a member of PEP:

Have you done your WRAP (Wellness Recovery Action Plan)?YesNo

If “No” would you like to do your WRAP in near future?YesNoMaybe

Any special needs?YesNoNot Sure

If Yes Please explain:

Any medical condition?YesNoNot Sure

(i.e. heart condition, diabetes, epilepsy)

If Yes Please explain:
Did you receive an orientation package?YesNo

(i.e. calendar of event, brochure, members bill of rights, coffee coupon)
For further information, please visit our website or search for us on Facebook

Did you complete Ontario Common Assessment of Need (OCAN) Core in last 6 month?YesNoNot Sure

Are you an individual with Mental Health and or Addiction Concerns?YesNo

(Defined as someone who is using and/or has used the mental health and or addiction system, including inpatient, outpatient or any type of counselling or 12 steps.)

We would like to invite any interested member to apply to sit on any of our committees. Anyone interested should contact the Program Manager for more information.
Appointment to a committee is subject to approval by the Board of Directors.
We value your input, please become an active participant in PEP.
All information contained in this form will be handled in accordance with the People for Equal Partnership in Mental Health Confidentiality Policy.