Sisters Dialogue Mental Health Referral Form
Please fill out this form to participate in Sisters Dialogue Mental Health Referral Program. Information collected will be kept in confidence and the data will be used for reporting outcomes to our funder only. No identifying elements, except general demographical information eg. age group, ethnicity etc. will be used. If you have any questions, please email sistersdialogue@gmail.com.

Only Muslim women residing in Edmonton are eligible. 

For U of A or MacEwan students reaching out, please write University4Palestine on the referral question. You do not have to be a Muslim woman to receive this support.

Learn more about Sisters Dialogue: https://sisters-dialogue.ca/
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Email *
Full Name *
If you were referred to us, please provide their name/s.
Age Group
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Do you identify as a Muslim woman? *
Where do you live? *
Ethnicity (please include all groups you identify with) *
Terms and Conditions: 1. Sisters Dialogue Mental Health Referral Program covers up to 5 therapy sessions with a culturally safe Therapist, who is contracted by us to provide this service. 2. This referral is voluntary and you may opt out at anytime. 3. The 5 sessions may be scheduled anytime within 3 months from the first session or before the end of the program date (whichever is earlier). 4. If you require an extension of this service, or no longer require the sessions, please let us know via email (sistersdialogue@gmail.com).   5. This program will end on December 31, 2024, and any unused sessions will be forfeited. 6. After registration, you will be emailed information on how to schedule an appointment with a  Therapist (we currently work with 3 therapists). If you do not hear from us after 5 working days, please contact us. 7. All participants will have to answer a short, confidential survey after using this service. 8. Please note that you must follow each Therapist's cancellation notice timeline. If you miss a scheduled appointment without providing ample notice to the therapist, Sisters Dialogue will be charged a cancellation fee, the cost will be transferred to the client. *
Disclaimer: Sisters Dialogue will not assume responsibility, nor be held liable for any damages whatsoever incurred as a result of this referral program. *
A copy of your responses will be emailed to the address you provided.
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