I am seeking counselling

Your request will be forwarded to an available counsellor during office hours. In case of emergency please call 211 or 911. The counsellor will provide you with information regarding sliding-scale fees for services at your initial consultation.

Fields marked (*) are required to submit this form. Any information you submit will be handled in strictest confidence and according to our Privacy Policy.

Your name (*)

Your email (*) - if you do not have an email address you may use confidential@thecarecentre.org

Your age:

Your address:

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? (*)

Best number to call you on:

May your counsellor leave a message at this telephone?
YesNo

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: