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Referral for Counselling Services
PLEASE READ: For internal use only.
Please make sure that the individual you are referring is aware of the various service options. For those applying for the
Community Counselling Program
, they must be aware that such service is
not
a crisis or emergency service, that it is also a limited service.
*
Indicates required field
Name of Individual
*
First
Last
[object Object]
Referral completed by
*
ACE Score
*
Please provide score out of 10 and out of 9 (section 1 and 2)
Reason for Referral/Presenting Problem
*
Telephone
*
Email
*
Can we leave a message?
*
Yes
No
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.
Type Name
*
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.
*
Yes
No
Service Option
Services
*
Free - Community Counselling Program
Free-First Responders Community Mental Health Services
Fee for service - Out of Pocket
Fee for service - Insured | covered
Social Development- Service Provider
Victim Services- Service Provider
Sexual Violence on Campus- Service Provider
University Student Benefits
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!
Submit
Home
About
Our Team
Community Counselling Program
First Responders Community Mental Health Services
Ask a Therapist
Contact
General Mental Health
Our Approach
Trauma Recovery
Specialized Approaches
Groups
Learning at lunch
Our Services
Pricing
Coverage
Trainings
Supervision