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    Service Request Form

    We at New Horizons Rehabilitation Services Inc. understand that you may not be able to drive to Listowel in order to ask for our services. We also understand that you may work during the hours that we are open. This is no longer a problem. Simply fill out the form below choosing your desired service and we will get back to you as soon as possible. Please note that we are unable to travel out of the country or province for treatments.

    Please Fill In All Fields

    * Required Fields

    YOUR INFORMATION
    Identify Yourself:
    Name: *
    Date Of Birth: MM: - DD: - YYYY: *
    Gender: *
    Contact Information:
    Street Address: *
    City: *
    Postal Code: *
    Home Phone: ( ) - *
    Work Phone: ( ) -
    E-Mail: *
    Select Physiotherapy Service:


    If "Other", please specify:

    Select Counselling Service:


    If "Other", please specify:

    Occupational Therapy:


    If "Other", please specify:

    Kinesiology Services


    If "Other", please specify:

    Consultations and Evaluations


    If "Other", please specify: