Referral

Referral for Counselling Services

PLEASE READ: Breelove Counselling is a private, fee-for-service offering one-to-one therapy,groups, and training's. Individuals interested in the Community Counselling Program (CCP) are advised to know that this is not a crisis program or emergency service, this program is accessible by referral only and provides free counselling. If you are self-referring, please contact CMHANB to access the online Counselling Clinic, once seen by a Counselling Therapist/Intern, you will have access to the CCP.

* 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 - Community Counselling Program Fee for service - Out of Pocket Fee for service - Insured | covered Social Development- Service Provider Victim Services- Service Provider University Student- student # required

Submit