Program Calendar Program Intake

Note: Programs, workshops, and services are currently reserved for Thames Valley Family Health Team patients only.

Program Intake Form

Thank you for expressing interest in a Thames Valley Family Health Team program. Please note that completing this form does not register you for a specific date and time. We will add you to the next available program based on travel preferences.
  • Information left may include program name, date, time, and/or location.
  • Please indicated which provider referred you to the group. If name is unknown, please indicate what profession. If still unknown, please indicate "unknown". (Examples include physician, Nurse Practitioner, Nurse, Social Work, Dietitian, etc.)
  • Please select the location of your family physician's office from the list below. Note: Programs, workshops, and services are currently reserved for Thames Valley Family Health Team patients only.
  • This field is for validation purposes and should be left unchanged.

Your health information is treated with respect and we work hard to protect your privacy and the security of the information you provide. Access to the information you have provided is available only to those who need to know because they are involved in referring you or coordinating, delivering, or evaluating the resources associated with group programming.  We will not share this information outside of our organization without your permission.