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Referral for Counselling Services
PLEASE READ: For internal use only.
Please make sure that the individual you are refering is aware of the various service options. For those applying for the
Community Counselling Program
, they must be aware that such service is
a crisis or emergency service, that it is also a limited service.
Indicates required field
Name of Individual
Referral completed by
Please provide score out of 10 and out of 9 (section 1 and 2)
Reason for Referral/Presenting Problem
Can we leave a message?
Additional Information| # attempt
For Release of Consent
I give permission to
Name of Agency or Individual
to share any information necessary within Breelove Counselling in order to secure services on my behalf. I understand that information will only be shared when necessary to meet the requirements for counselling therapy.
By typing your name (client), you are providing consent for the release of information based on the request herein.
I agree to the release of consent herein.
Free - Community Counselling Program
Fee for service - Out of Pocket
Fee for service - Insured | covered
Social Development- Service Provider
Victim Services- Service Provider
University Student(BPAS) benefit # required
Community Counselling Program: This is not a crisis program or emergency service. Fee - for -Service: Please visit the Access and Rates page of our website for booking availabilities. This service may be covered by your insurance provider, through victim services, or other funding means. Training and Facilitation: I will connect with you via email within 48 hours. Thanks for reaching out, chat soon!
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