Refer a person

Are you a professional and would like to refer someone to AQPA? Please complete the form below. We will contact you as soon as possible.

Information on the professional referent and the person referred

Nom* (referent)

First name* (referent)

Email (referent)

Telephone* (referent)

CRSSS, CISSS, CIUSSS (if applicable)

REFERRED PERSON

I have the consent of the referred person to transmit their information to AQPA

Name* (referred)

First name* (referred)

Telephone* (referred)

Email (referred)

Postal code (referred)

Please explain to us in a few words the reason for your request.

Subject of your request

Group workshops (people with aphasia) Friendly visits (people with aphasia) Support services for caregivers Other