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Welcome to our online counselling referral form.

Before you begin…..

If you are in crisis or need immediate support, please call HERE 24/7 at 1-844-437-3247.

If you are thinking of suicide, call or text 9-8-8, any time.

If you are completing this form for someone else, please enter the information about the person who will be receiving services (e.g., if you are requesting counselling for your child, please enter your child’s name, birthdate, etc.).

Please answer all questions as much as possible. Mandatory questions are marked with *. 

The information you submit is private and confidential. It will be viewed by an Intake Worker and later by the counsellor assigned to you.

When you submit this form, your request will be recorded and you will be contacted by an Intake Worker when an appointment becomes available. At that time, the Intake Worker will discuss your counselling needs and complete a fee assessment.

Please note: Services are available to those who live in Waterloo Region.