Accueil Action collective CHSLDCHSLD Form

CHSLD Form

CHSLD Class Action Lawsuit Form

Who is completing the form?*
Relationship between the claimant and the CHSLD resident
Name, address and other contact details of the representative(s)
Email address of CHLSD representative
Phone number of CHLSD representative
Last name of CHSLD resident*
First name of CHSLD resident*
Last residential address of CHSLD resident (please enter full address)*
Current address or address at the time of death
Email address of CHLSD resident
Phone number of CHLSD resident
In the region (1)*
(1) If the resident has stayed in more than one facility, please fill in a separate form for each facility.

Please first choose the CIUSSS or the CISSS of the CHSLD where you reside, this choice will then display the list of CHSLDs for this CIUSSS or this CISSS.
The user resided in the CHSLD*

If the CHSLD where you live is not included in the list below, you are potentially not covered by the class action. In this case, please contact us directly.
The user resided in the CHSLD*

If the CHSLD where you live is not included in the list below, you are potentially not covered by the class action. In this case, please contact us directly.
The user resided in the CHSLD*

If the CHSLD where you live is not included in the list below, you are potentially not covered by the class action. In this case, please contact us directly.
The user resided in the CHSLD*

If the CHSLD where you live is not included in the list below, you are potentially not covered by the class action. In this case, please contact us directly.
The user resided in the CHSLD*

If the CHSLD where you live is not included in the list below, you are potentially not covered by the class action. In this case, please contact us directly.
The user resided in the CHSLD*

If the CHSLD where you live is not included in the list below, you are potentially not covered by the class action. In this case, please contact us directly.
The user resided in the CHSLD*

If the CHSLD where you live is not included in the list below, you are potentially not covered by the class action. In this case, please contact us directly.
The user resided in the CHSLD*

If the CHSLD where you live is not included in the list below, you are potentially not covered by the class action. In this case, please contact us directly.
The user resided in the CHSLD*

If the CHSLD where you live is not included in the list below, you are potentially not covered by the class action. In this case, please contact us directly.
The user resided in the CHSLD*

If the CHSLD where you live is not included in the list below, you are potentially not covered by the class action. In this case, please contact us directly.
The user resided in the CHSLD*

If the CHSLD where you live is not included in the list below, you are potentially not covered by the class action. In this case, please contact us directly.
The user resided in the CHSLD*

If the CHSLD where you live is not included in the list below, you are potentially not covered by the class action. In this case, please contact us directly.
The user resided in the CHSLD*

If the CHSLD where you live is not included in the list below, you are potentially not covered by the class action. In this case, please contact us directly.
The user resided in the CHSLD*

If the CHSLD where you live is not included in the list below, you are potentially not covered by the class action. In this case, please contact us directly.
The user resided in the CHSLD

If the CHSLD where you live is not included in the list below, you are potentially not covered by the class action. In this case, please contact us directly.
The user resided in the CHSLD*

If the CHSLD where you live is not included in the list below, you are potentially not covered by the class action. In this case, please contact us directly.
The user resided in the CHSLD*

If the CHSLD where you live is not included in the list below, you are potentially not covered by the class action. In this case, please contact us directly.
The user resided in the CHSLD*

If the CHSLD where you live is not included in the list below, you are potentially not covered by the class action. In this case, please contact us directly.
The user resided in the CHSLD*

If the CHSLD where you live is not included in the list below, you are potentially not covered by the class action. In this case, please contact us directly.
The user resided in the CHSLD*

If the CHSLD where you live is not included in the list below, you are potentially not covered by the class action. In this case, please contact us directly.
The user resided in the CHSLD*

If the CHSLD where you live is not included in the list below, you are potentially not covered by the class action. In this case, please contact us directly.
The user resided in the CHSLD*

If the CHSLD where you live is not included in the list below, you are potentially not covered by the class action. In this case, please contact us directly.
Date ⁽²⁾

⁽²⁾ Following the judgement authorizing the class action, people can submit their claims for any period from July 9^th, 2015.
From*
YYYY slash MM slash DD
To*
YYYY slash MM slash DD
Do you need to meet with the attorneys who are handling the class action lawsuit?*
- Yes
- No
Short description of the alleged facts concerning the inadequate or insufficient care and services and/or of the poor quality of healthcare and social services received at the CHSLD

If you have any documents or materials related to your allegations that you wish to send us, please attach them to the email address below.

Email: chsld@larochelleavocats.com

Please note that the information you share with us in your form will be kept strictly personal and confidential. We are fully aware of the risk of reprisals for those who denounce the conditions in CHSLD, and we are committed to protecting the data of residents.

CHSLD Form

CHSLD Class Action Lawsuit Form

Date (2)

Date ⁽²⁾