Who can submit a Referral / Request for Outreach Services?

You should submit a Referral / Request for Outreach Services if you are an individual experiencing domestic violence and you need support, or if you are a professional and you are supporting someone experiencing domestic violence.

Domestic violence can include emotional, physical, sexual, and/or financial abuse or coercive control. At Women’s Crisis Services of Waterloo Region, we support women, transgender and gender-diverse individuals 16+ (and their children) who are experiencing domestic violence.

If you are in immediate danger, call 911.

Filling Out Referral Form

Please fill out all mandatory fields so we can determine how to best support you. The information you provide will not be released to any individual or organization without your expressed consent, unless required by law.

After submitting this form, you will be contacted by an Outreach Worker. Due to demand, there may be a wait of up to a week before someone is available to connect with you. Please be aware the Outreach Workers do not provide immediate crisis support.

*If you are in need of immediate crisis support, please contact our support lines at either: 519-653-2422, 519-742-5894, or access our online chat in the bottom right corner of this website.

Once this form has been submitted, an electronic file will be generated for our records. This record will only be accessible by Women’s Crisis Services of Waterloo Region.

If you need to update your information or need technical support in completing this form, please contact our support lines at 519-653-2422 or through our online chat.

Sorry, this form is temporarily unavailable. Please reach out using our contact page, or our helper, if you are in need of help!