Please complete the secure form below if you are interested in starting your counselling journey. The information you provide will help us connect you with the best counsellor to meet your needs.
DATE OF BIRTH (YYYY/MM/DD):
ARE YOU A RESIDENT OF BRITISH COLUMBIA?
ARE YOU A REGISTERED WITH FIRST NATIONS HEALTH AUTHORITY?
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?
ARE YOU OPEN TO SEEING AN ALLY COUNSELLOR IF AN INDIGENOUS COUNSELLOR IS NOT AVAILABLE?
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.