REQUEST FOR THERAPY AND COUNSELLING APPLICATION

Fields marked with an * are required.

CONTACT INFORMATION
Patient's First Name*   
Patient's Last Name*   
Email:*   
Phone:*   
Address:*   
City:*   
Province:*   
Postal Code:*   
CASE INFORMATION
CASLPO Case File #:   
Name of practitioner (Audiologist or Speech-Language Pathologist) whom you are/were sexually abused by:*   
The abuse started on:   
I am submitting this application to request funding for therapy and counselling (funding) as a result of this sexual abuse. The date my therapy/counsel began (or will begin):   
I understand that the Patient Relations Committee (PRC) will review my application and will decide whether I qualify for this funding. I will be notified of the PRC's decision in writing.*   
My therapist/counsellor is:

I understand that all payments will be made directly to the therapist/counsellor. I understand that my therapist/counsellor will need to comply with the requirements of the PRC.   
To be eligible for funding, I understand that I cannot be in a family relationship with my therapist/counsellor.*   

This will be sent to:
Patient Relations Committee
c/o Registrar of College of Audiologists and Speech-Language Pathologists of Ontario
3080 Yonge Street, Suite 5060
Toronto ON M4N 3N1



This website is intended to provide information to the public and registrants. Should there be difference in documentation previously distributed to CASLPO registrants, it is up to the registrant to source the latest version posted on the CASLPO website. Note: the term "member" and "registrant" are used interchangeably throughout CASLPO's website and documents. Both terms are synonymous to "member" as defined in the Regulated Health Professions Act, 1991, the Audiology and Speech-Language Pathology Act, 1991, and the Regulations under those Acts.