MARC/PAR Referral Form - CAS of Oxford County

If you have been ordered by the courts to attend the MARC / PAR Program, please fill out our MARC/PAR Referral form.

Registration is to be completed within 48 hours of your court order.

"*" indicates required fields

Personal Details

Name*

First Name Last Name

Date of Birth*

Gender (How do you identify?)*

Contact Information

Current Address*

Number and Street Name Unit Number City Select Province Postal Code Country

Daytime Phone Number*

Evening Phone Number*

Email Address*

Best Way/Time to Reach You?

How did you hear about the MARC / PAR Program?*

Date you were court ordered into the program*

Were charges laid by the OPP or WPS?*

OPP

WPS

Do you have children under the age of 16 years?*

Yes

Victim or Partner Information

Name*

First Name Last Name

Date of Birth*

Address*

Number and Street Name Unit Number City Select Province Postal Code Country

Daytime Phone Number*

Evening Phone Number*

Email Address (leave blank if not applicable)

What is your current relationship status with this person?*

Description of Incident

Please provide a brief an outline of the situation that resulted in you being charged and referred to the MARC / PAR Program?*

File

Max. file size: 10 MB.

Consent to Release Information – Family Violence Counselling Program*

I provide consent for my information to be gathered and shared with the Family Violence Counselling Program for the purpose of a referral. I understand that if the Family Violence Counselling Program is unable to reach me at the numbers provided they will contact the Woodstock Crown’s Office and the charging police station. This consent can be withdrawn at any time.

Consent to Release Information – Crown Attorney’s Office*

I provide consent to the Family Violence Counselling Program obtaining and/or releasing information related to me from/to the Crown Attorney’s Office, located at 415 Hunter Street, Woodstock ON, N4S 4G6, phone: 519-537-2611 for the purpose of registration and participation in the MARC/PAR Program. This consent can be withdrawn at any time. Unless withdrawn, this consent shall remain valid for 12 months from date consent was signed.

Consent to Release Information – Court Office*

I provide consent to the Family Violence Counselling Program obtaining and/or releasing information related to me from/to the Court Office, located at 415 Hunter Street, Woodstock ON, N4S 4G6, phone: 519-539-6187 for the purpose of registration and participation in the MARC/PAR Program. This consent can be withdrawn at any time. Unless withdrawn, this consent shall remain valid for 12 months from date consent was signed.