Intake Form

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Digital Intake Form

The purpose of this form is to collect initial information to begin the application process for our OTTER program. Once we receive your submission, we will get in touch to schedule an intake interview, which can take place via phone, TEAMS / Zoom, or in person.


If you require assistance with completing this form, please contact us at 204-441-8542 or otterprogram2024@gmail.com / coordinator@otterhome.ca.


Rest assured, all information you provide will remain confidential in line with PHIA regulations. For further information, please refer to OTTER Home Inc.'s Privacy Policy.


Please note that we will need the following intake documentation before your admission to OTTER. To download these forms, simply click the download files button below.

Step 1

Download and Complete Intake Form.

Download Files

Step 2

Complete Step 1 form and upload below or Fax completed form to 204-703-3000

Participant Intake Form


Referral Information

Participant Information


Before submitting this document, please ensure that all required fields are fully completed. Additionally, verify the accuracy of your responses by using the attestation provided below.

Attestation Clause


By submitting this form electronically, I hereby attest that all information provided herein is accurate and complete to the best of my knowledge. I understand that any false or misleading information may result in penalties, including but not limited to, rejection of the form, legal action, or other consequences as deemed appropriate by the relevant authorities.


I acknowledge that my digital submission serves as my electronic signature, and I agree to be bound by the terms and conditions associated with this form.

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