PRO-BONO COUNSELLING APPLICATION FORM

Student Counsellors are available from the beginning of October to the end of March, Monday to Friday, during regular business hours

Our pro bono counselling spots are offered by our graduate student counsellors and are specifically reserved for individuals who are unable to afford therapy services but are committed to attending regular sessions. Eight sessions free of charge are provided through this initiative. We encourage applicants to carefully assess their financial situation when applying to ensure these limited opportunities are available to those who truly need them.

PRE-INTAKE
Please acknowledge that you have reviewed and understand the following information before completing the online intake form:

1. Crisis Counselling Policy

I understand that Metro Vancouver Indigenous Counselling is not an emergency service and may not be suitable for individuals seeking immediate assistance.

PERSONAL INFORMATION

FIRST NAME:

LAST NAME:

PREFERRED PRONOUNS:

EMAIL ADDRESS:

TELEPHONE NUMBER:

DATE OF BIRTH (YYYY/MM/DD):

MAILING ADDRESS:

PERSONAL HEALTH NUMBER (PHN):

ARE YOU A RESIDENT OF BRITISH COLUMBIA?
YesNo

WHICH OF THE FOLLOWING SERVICES IS YOUR PREFERENCE? (SELECT ALL THAT APPLY):
Please note: In person counselling is currently only available in Vancouver on a limited basis.
Telephone CounsellingOnline Video CounsellingIn-person Counselling

IF THE COUNSELLING PREFERENCE YOU SELECTED ABOVE IS NOT AVAILABLE, WOULD YOU BE OPEN TO ANOTHER OPTION? (PLEASE NOTE: THERE IS A LONGER WAIT TIME FOR IN PERSON COUNSELLING SERVICES)
YesNo

REASONS FOR SEEKING COUNSELLING:

WHAT IS YOUR AVAILABILITY FOR APPOINTMENTS?:

REFERRING ORGANIZATION (Examples: NEC, Luma Medical Centre, NVIT, etc.):

ADDITIONAL INFORMATION:

EMERGENCY CONTACT

FULL NAME:

TELEPHONE NUMBER: