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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 not a crisis or emergency service, that it is also a limited service.
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    Please provide score out of 10 and out of 9 (section 1 and 2)

    For Release of Consent

    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.

    Service Option

    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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  • Home
  • Counselling Therapy
  • Fees
  • Our Team
  • Supervision
  • Ask a Therapist