The Health Communication Unit

To arrange a consultation or regional workshop, please complete the form below or print off a PDF version of the request kit and send it to us. We will work with you to develop a plan for the consultation or training that will best meet your needs.

Please enter the six characters you see in the image above. (This is to prevent automated spammers from using this form)
1. Applicant Information*
First Name		(required)
Last Name		(required)
Organization
Job Title
Address
City
Province		Services are available free to residents of Ontario only.
Postal Code
Telephone
Tel. Extension
Fax
Email		(required)
Please select whether you would like to receive information by Fax or Email

2. What type of organization are you representing?

3. Please identify your region.

4. Please describe your role within your organization (please check all that apply).

5. Please select the type of assistance you need from the following list (one or more).

6. Briefly describe the situation in your community or agency and explain what you want to accomplish through this consultation or training.

7. Have you spoken to anyone from PHO about this topic/consultation already? If so, who, and (briefly), what was discussed?

8. Preferred timing for the consultation or training?

9. Due to steadily increasing budget pressures, we request that our clients pay part or all of the travel costs associated with regional workshops, presentations and consultations (If costs are prohibitive, we may be able to explore alternatives such as webinars). Are you willing to pay some or all travel costs associated with this service request?

10. Anything else you'd like us to consider?

*We collect the information on this form for administrative and reporting purposes. None of your contact information is shared with or accessible to anyone other than Public Health Ontario. If you have any questions, please contact us.

Back to Health Promotion Capacity Building Services and Resources

Ontario Agency for Health Protection and Promotion

Service Request Form

1. Applicant Information*