Form: Counselling Request - NightShift Street Ministries

I am seeking counselling

Your request will be forwarded to an available counsellor during office hours.
The counsellor will provide you with information regarding sliding-scale fees for services at your initial consultation.
While we will do our best to put you in touch with a counsellor, referral does not guarantee service.
Any information you submit on this page will be handled in strictest confidence and according to our Privacy Policy.

I agree and consent to the collection of my information for the purpose of putting me in touch with a counsellor.(Required)

Yes

Name:(Required)

First Last

Email:(Required)

If you do not have an email address, you may use confidential@thecarecentre.org

Enter Email Confirm Email

Address:

Street Address City Province Postal Code

Your age:

Phone:

May your counsellor leave a message at this phone?

Yes

Referred by:

If you have help completing this form, please include the name of the person who helped you.

What is the best way for a counsellor to contact you?(Required)

Contact information:

Other way to contact you if email or telephone not an option:

Which DAY are you available for counselling?

What TIME works for you for counselling?

Any message:

Please share any other relevant information for the reason of referral.