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Outreach Program Intake Form

Anova’s Outreach Program provides flexible services and supports to individuals (and their families) living in the community who have experienced violence and abuse. They assist and support all genders with their needs and goals and to develop transition plans to live safer lives.

We are asking you for some personal information to better understand who we serve and what the needs are. The information will be kept confidential and only used to better understand your situation and how we can improve our services. If you have any questions or concerns about why we ask this information, please let us know.

Fields marked with * are mandatory.








    Children Information

    Child #1

    Child #2

    Child #3

    Child #4

    Identified Abuser

    Confidentiality Agreement

    I understand that any and all information that I choose to share with the Anova will be kept private and confidential and will not be shared with anyone without my written consent, with the following exceptions:

    • If Anova has reason to believe that I am going to hurt myself or someone else, Anova has an obligation to call the London Police and connect me with the support I need.
    • If Anova has reason to believe that a child under the age of sixteen is being abused or is at risk of being abused (including emotional harm which can be caused by witnessing domestic violence), Anova has a duty to report the information to the Children’s Aid Society.
    • If the court requests a copy of your file, Anova is obligated to provide them with a copy of the entire file or any part that they wish to have. Anova can also be asked to testify in your case.

    I understand and agree*