MARC PAR Referall Form

MARC/PAR REFERRAL FORM

Please provide the following information if you have been ordered by the courts to attend the MARC / PAR Program. Registration is to be completed within 48 hours of your court order.

If you would prefer to download the form and fill it out by hand, it is available to download below. You may fax the completed form to the attention of Family Violence Counselling Program at 519-421-0123.

Download: MARC/PAR Referral Form

Contact Information

First and Last Name

Birthdate (MM-DD-YYYY)

Gender (How do you Identify?)

Please include street name and number, apartment, P.O. Box, R.R.#

Current Address

City/Town

Postal Code

Daytime Phone Number

Evening Phone Number

Your Email (leave blank if not applicable)

Best Way/Time to Reach You?

How did you hear about the MARC / PAR Program?

Date you were court ordered into the program
(MM-DD-YYYY)

Were charges laid by the OPP or WPS?

Do you have children under the age of 16 years?

Victim or Partner Information

Name

Date of Birth (MM-DD-YYYY)

Street Address (street name, #, apartment, P.O. Box, RR#)

City/Town

Postal Code

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?

Please click the NEXT button to provide your consent for the information you've provided to be collected and shared with the Family Violence Counselling Program, the Crown Attorney's Office and the Court Office.

PART 2: Consent Regarding Personal Information

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 This consent can be withdrawn at any time.

Client Electronic Signature
Please type your first and last name

Acceptance Checkbox

I understand that checking the box below constitutes a legal signature confirming that I consent to my information being shared as described above.

Date of Submission (MM-DD-YYYY)

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.

Acceptance Checkbox

I understand that checking the box below constitutes a legal signature confirming that I acknowledge and agree to the terms of this form.

Date of Submission (MM-DD-YYYY)

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.

Acceptance Checkbox

I understand that checking the box below constitutes a legal signature confirming that I acknowledge and agree to the terms of this form.

Date of Submission (MM-DD-YYYY)

Click Below to Proceed

Thank you for your submission!

An agency staff member will contact you regarding your registration.