Family Services Ottawa
312 Parkdale Avenue
Ottawa  Ontario  K1Y 4X5


Phone: (613) 725-3601,
Fax: (613) 725-5651,
Email: info@familyservicesottawa.org
Referral Type:
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Referral:
Service Request ID
Date: 2025-05-05 05:59
Status: Draft
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FSEAP professional and confidential employee/member and family assistance and support services are available to eligible employees/members and their immediate family members. Please answer the following questions to initiate your service request. No personal or identifiable information is shared with your organization or others without your consent. Please note: Your benefit may not include all services described in this form. Gain more information from your benefits material or by contacting your Human Resources/Benefits department.

Not all situations are suited to our online service request process. For that reason, we assess for situations that may require a more urgent response and a telephonic assessment to better understand your current needs.

If you believe there is a risk of harm to you or anyone else at this time, please do not proceed with this form. Instead, please call your local emergency services or our toll-free number at 1-800-668-9920; 24 hours a day and a representative will connect you to the immediate support you require.

Please tell us who you are
Client
First Name
Last Name
DOB
Select Date Clear Date
Gender
Address Line 1
Address Line 2
City
Location/County
Postal Code
Province
Country
Phone (Home/Main)
Permission to call?
Phone (Home/Main)
Permission to leave a message?
Phone (Home/Main)
Permission to text?
Phone (Home/Main)
Email
Permission to contact via Email
Company providing EAP (Employee Assistance Program) Benefit (no acronyms):
How did you hear about your FSEAP Program?
Eligibility Type:
I am requesting the following service:
Reason(s) for the referral
Referral Source
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