Online Service Request
If you are experiencing a life-threatening situation, or any other urgent issue call 911 or immediately go to your closest emergency room or contact our 24/7 toll-free number at (800) 661-8193
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Participant’s primary language?
What type of counselling are you asking for?
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Details
Reason you are seeking support?
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Have you ever received any support or treatment in the past? If so, briefly explain
Are you currently experiencing any thoughts of hurting yourself or anyone else, or are you experiencing any violence or abuse? If so, please explain
Do you have any concerns related to alcohol or drugs? If yes, please explain
Do you have any concerns regarding child or vulnerable adult protection?
Do you wish to be referred to the same counsellor as before?
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Name of requested counsellor
Counselor Characteristics Required
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May we contact you via your listed email address or phone number and leave a message?
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