Consent Form


Please click the button below and complete our request for service form.


Our team will review your request and an available therapist will be matched based on your identified need.


You will be contacted by the Registered Social Worker Therapist to schedule the initial consultation which is provided at no cost.




Telus Health

Direct Billing Form

Client Satisfaction Form

Connect with us.

​​Request for Service Form

530-3336 Portage Avenue Wpg,Mb R3K 2H9
+1.2042537072 • info@mobilesocialclinic.com

Confidentiality and the overall Security of our clients is our top priority. In order to maintain excellence in this area our therapists operate within the Jotform platform. 

Copyright © Mobile Social Clinic Inc. All Rights Reserved.
IF YOU ARE IN A LIFE THREATENING SITUATION- DO NOT USE THIS SITE CALL 204-940-1781 OR 911

Covid-19 Forms

HIPPA & SECURITY