Referral / Request for Outreach Services

Who can submit a Referral / Request for Outreach Services?

You should submit a Referral / Request for Outreach Services if you are an individual experiencing domestic violence and you need support, or if you are a professional and you are supporting someone experiencing domestic violence.

Domestic violence can include emotional, physical, sexual, and/or financial abuse or coercive control. At Women’s Crisis Services of Waterloo Region, we support women, transgender and gender-diverse individuals 16+ (and their children) who are experiencing domestic violence.

If you are in immediate danger, call 911.

Filling Out Referral Form

Please fill out all mandatory fields so we can determine how to best support you. The information you provide will not be released to any individual or organization without your expressed consent, unless required by law.

After submitting this form, you will be contacted by an Outreach Worker. Due to demand, there may be a wait of up to a week before someone is available to connect with you. Please be aware the Outreach Workers do not provide immediate crisis support.

*If you are in need of immediate crisis support, please contact our support lines at either: 519-653-2422, 519-742-5894, or access our online chat in the bottom right corner of this website.

Once this form has been submitted, an electronic file will be generated for our records. This record will only be accessible by Women’s Crisis Services of Waterloo Region.

If you need to update your information or need technical support in completing this form, please contact our support lines at 519-653-2422 or through our online chat.

    I am
    Professional Making Referral:
    Before submitting this form, please make sure that the client has provided their consent for this referral.
    Please enter some form of contact information.
    Client Information:

    (Please include your entire name, not just initials)

    (Please include your entire first name)

    (Please include your entire last name)

    Please note: Woman's Crisis Services of Waterloo Region provides services to women, transgender and gender-diverse individuals age 16+. If you or your client is younger than this, please contact Family and Children’s Services at 519-576-0540.

    (Ideally, one that is safe for us to reach you at)

    (Ideally, one that is safe for us to reach you at)

    Please enter some form of contact information.
    Married PartnerCommon Law Relationship/Living togetherEx or past partner (if separated)Dating Relationship/Not Living TogetherFamily Member

    Please pick the closest fit

    Mother, Father, etc.

    If you are in need of emergency shelter, please contact our support lines at either: 519-653-2422, 519-742-5894, or access our online chat in the bottom right corner of this website. If you are in immediate danger, call 911.

    Please provide as much detail as you are comfortable with

    For example: Family Law Services, Other Legal Services (Criminal/Immigration), Housing Support Services and Information, Safety Tips and Strategies, Community Resources Information, Mental Health Services Information, Substance Use Services Information, Cultural and Community Supports, Family Supports - Day Care Information, Family Supports - Children's Programming/ Counselling

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