Accessibility Feedback Form

Community Support Connections is committed to providing services that are accessible for everyone.

By filling out this form, you will be submitting your feedback to our Manager of Quality, who will work with our staff to seek effective improvements and solutions.

Alternatively, you may call our office at 519-772-8787 and submit your feedback over the phone.

Question Title

* Please provide your name and contact information so that we can assist you.

Name (first and last)

Address

Address 2

City/Town

State/Province

Postal Code

Email Address (if applicable)

Phone Number

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* What is the name of the service that was provided.

Question Title

* Please tell us the date and time of the service.

Date and Time of Service

Date

Time

AM/PM

Question Title

* Was the service provided in a manner that is accessible to you?

Question Title

* Please tell us what Community Support Connections can do to make this service more accessible?

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* Would you like someone from Community Support Connections to contact you?