Referral

Referral for Counselling Services

PLEASE READ: Breelove Counselling is a private, fee-for-service offering one-to-one therapy. Individuals interested in the Community Counselling Program are advised to know that this is not a crisis program or emergency service. You or the person you are referring, will be assigned the earliest available Counselling Therapist with expertise in the problem area, unless a preference is expressed below.

* Indicates required field

Name of Individual *

First

Last

Referral completed by *

Company|Organization|Clinic Name *

Reason for Referral/Presenting Problem *

Telephone *

Email *

Can we leave a message? *

Additional Comments *

For Release of Consent

I give permission to *

to share any information necessary with Breelove Counselling in order to secure resources on my behalf. I understand that information will only be shared when necessary to meet the requirements for counselling.

I authorize Breelove Counselling to share my records with *

Type Name *

I agree to the release of consent herein. *

Yes No

Service Option

Services *

(FREE/Survey) Graduate Student/Community Counselling Program ($40 -150/hr) Licensed Counselling Therapist|Canadian Certified Counsellor (Custom) Training and Facilitation

Submit

Referral Form

Referral for Counselling Services

For Release of Consent

Service Option