Request for Free Counselling

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

PLEASE NOTE THAT DUE TO OVERWHELMING DEMAND ALL NEW SIGNUPS WILL BE ADDED TO THE WAITING LIST. IF YOU ARE IN DANGER PLEASE SEEK COUNSELLING ELSEWHERE OR CONTACT EMERGENCY SERVICES. If you are an ACB Woman experiencing depression, anxiety, low self-esteem, grief, feelings of unworthiness, sadness etc... Help is available. Three free confidential counselling sessions from Black Therapist in either English or French. Complete the signup process below:

Confidentiality: Please note that your contact information will only be shared with the counsellor you requested. Information shared during counselling sessions is confidential between you and your counsellor. Statistical information only on the demographic groups served such as age groups etc.. (not your personal identifiable information) will be shared with our funder the Canadian Women's Foundation. All counsellors are licensed and in good standing with their accrediting colleges. *

I acknowledge that I have read and understand

Required

Your First and/or Last Name? *

Email address Best / Safe to contact you) *

Telephone Number Best / Safe to Contact you *

Best (Safe) way to contact you? *

Telephone

Either

Can a message be left at this telephone number? *

Yes

What options would you like to attend? *

Group Counselling

One-on-one Counselling

Drop-in Counselling

Required

Counsellor Request (please note we will do our best to we will do our best to match you with that counsellor, however, if the counsellor is unavailable, you will be assigned another counselling professional) *

Melissa Saumur, MSW, RSW - Billingual

Bernadette Ingungu, RP(Q) - Billingual

Lori-Ann McDonald, RSW (English)

Nicole Bloomfield, MSW, RSW (English)

Myriam Georges-Estigène, RP (Q), M.Ed, C. Psych, Bilingual

Fully Booked Not Available - Mamy Kalambay, MACP (She/Her/Elle), RP, Billingual

Fully Booked Not Available - Karoline Achille, M.A. RP(Q) Billingual

Fully Booked Not Available - Amma Gyamfowa, MSW, RSW (English)

Do you identify as Afro-Caribbean Black (ACB)? *

Yes

Current Marital Status? *

Married or common-law

Single never married

Divorced

Conjugal partners

Your current age? *

Optional: Do you identify as (select as many as apply to you)?

Woman

Trans

Two spirit

Non-Binary Peoples

Disabled

Immigrant

Refugees or Non-status

Racialized

Non-Racialized

Thank you for applying. The counsellor will contact you in the next three business days to schedule your appointment. Please note that for each scheduled session that you do not show up, you forfeit a free counselling sessions unless you have notified the counsellor within 3 business days. *

I acknowledge that I have read and understand these terms and conditions

Required

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms