Therapy Request Form

We’re here for you...

Our therapists help individuals impacted by a number of struggles, including racialized trauma, sexuality/gender identity issues, low self esteem, anxiety, depression, adjustment, system navigation difficulties, stress management issues, and negative thoughts.

Check out our list of therapists and fill out the form below to get started.

One-on-one Counselling

First Name*

Last Name*

Pronouns*

Phone*

Email*

Age*

Street

City*

Province*

How do you self identify?*

What is your marital status?

Which therapist are you interested in seeing?*

What condition are you seeking therapy for?*

What focus areas do you need support with?*

Do you have access to a device with internet?*

how many dependents do you support in your home?

Appointment Availability*

Approve Phone Consulation*

?

Approve Additional Assessment*

?

Enrolled In Clinical Counseling

I hereby read and understand all the One-on-One Counseling Policies and conditions for applying for this program. I answered the form truthfully.

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Therapy Request Form

We’re here for you...

Head Office:

Quadra Village,
Victoria BC

250-277-2545
info@sniwwoc.ca

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For general inquiries and donations, email us at info@sniwwoc.ca

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