ARE YOU A RESIDENT OF BRITISH COLUMBIA?
YesNo

ARE YOU A REGISTERED WITH FIRST NATIONS HEALTH AUTHORITY?
YesNo

IF APPLICABLE, INDICATE IF YOU ARE A:
Former Indian Residential School studentFamily Member of a former Indian Residential School studentFormer Indian Day School studentFamily member of a former Indian Day School student

NAME OF SCHOOL ATTENDED (REQUIRED IF YOU CHECKED ONE OF THE ABOVE):
Let us know what community your family is from if you do not know what school they attended

IF APPLICABLE, PLEASE DESCRIBE IF YOU ARE SEEKING SERVICES IN RELATION TO MISSING & MURDERED INDIGENOUS WOMEN & GIRLS:

DO YOU PREFER TELEPHONE OR ONLINE VIDEO COUNSELLING?
TelephoneOnline Video

ARE YOU OPEN TO SEEING AN ALLY COUNSELLOR IF AN INDIGENOUS COUNSELLOR IS NOT AVAILABLE?
YesNo

REASONS FOR SEEKING COUNSELLING:

WHAT IS YOUR AVAILABILITY FOR APPOINTMENTS?:

REFERRING ORGANIZATION AND/OR PROGRAM (Examples: NEC IJS, Luma Medical Centre, NVIT Justice Studies, etc.):
This information is important to help us match you with a counsellor who will best meet your needs.

ADDITIONAL INFORMATION: