Health Nexus (formerly OPC) is Ontario's leading bilingual health promotion organization.

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Service Request Form

To request Health Nexus's services, complete the form below and send it to us. We will work with you to develop a plan for the service that will best meet your needs. Please note that our services are currently available in Ontario only, in both French and English. We cannot guarantee a consultation with less than 6 weeks notice or a workshop with less than 3 months notice.

We may not be able to contact you immediately, but we will do so as soon as we can. If you require a quick response please e-mail us directly at or contact Health Nexus by telephone. Thank you in advance for your comments.

Date submitted:

1. Applicant information

Name:
Name of organization/group:
Title:
Address:
City:
Postal code:
Telephone:
Fax:
E-mail:
Website:

2. Please select the type of assistance you need from the following list (one or more).
Workshop	Information and resources
Consultation

3. Service desired in French or English? Please indicate.
English	French	English and French


4. Briefly describe what your organization or program does and whom it serves.



5. Please describe briefly the nature of your request. (50 words maximum)



6. When do you require these services?