*

First Name

Last Name

Phone number *

(###)

###

####

What are some of the challenges currently faced by the individual? (multiple choice)

Depression

Anxiety

Grief

ADHD

Eating disorder

Mood disorder

Academic pressure

Body image

Identity

Family dynamics

Substance use

Housing

Self-harm

Suicide

Trauma & PTSD

Other

➡️ Are there any current indicators of suicidal risk? *

yes

no

Choose all that apply:

They have previously attended sessions with a counsellor.

They are currently attending sessions with a registered counsellor.

They are currently benefiting from additional support services.

What barriers might this person be experiencing that are preventing them from accessing counselling services? *

No insurance coverage

Partial insurance coverage

The individual is experiencing a complex family situation, with parental or guardian dynamics contributing to their current challenges.

The individual is in a complex family situation where their parents or guardians are unwilling to financially support counselling sessions.

The individual is on a waitlist to access counselling but they need urgent support.

The individual's previous counsellor is no longer available and they need immediate support.

Other

*

By submitting this form, I acknowledge that Community is Medicine is solely providing financial support for counselling sessions and is not responsible for the content, process, or outcomes of the counselling services. While we may offer recommendations for counsellors we have worked with previously, these are provided as suggestions only. Community is Medicine assumes no liability or responsibility for the services provided by any professional counsellor to whom individuals are referred.