Quality Improvement Form

All information collected from this form will be kept confidential with the Mental Health Crisis Line

Please check appropriate box:
(* all fields are required)

* Select which services you are concerned about (you may check both boxes):*
- Crisis Line
- Local Crisis Team
Select geographic area:*
- Ottawa
- Prescott and Russell
- Renfrew County
- Stormont, Dundas & Glengarry and Akwesasne
Date and time (to the best of your ability) of the interaction:*
DD dash MM dash YYYY
: Hours

Minutes

AM/PM
Specifics of the concern:*
Contact information:
Please enter contact information where you may be reached for follow-up. Our follow-up may include gathering more information to help us properly address your concern or to inform you of measures we are taking to improve the quality of our services as a result of your participation in this process.
Name*
First Last
Email*
Phone*
*Required information. Feedback form will not be accepted without required information.