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ECMA Sound Minds Program - One-on-One Counselling
Thank you for your interest in counselling through the ECMA Sound Minds program. Please complete the self-referral form to share some information about yourself, your connection to the music community, and your current health needs.
This form should take approximately 10 minutes to complete. This information will be kept confidential and reviewed by our clinical therapist to help best direct and support you. You will be contacted within a week to discuss therapy.
If you have any questions, please contact
wellness@ecma.com
.
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* Indicates required question
Last Name
*
Your answer
First Name
*
Your answer
Preferred Name
Your answer
Preferred Pronouns
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Street Address
*
Your answer
City/Town
*
Your answer
Province
*
Your answer
Postal Code
*
Your answer
Phone Number
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Your answer
Is it okay to leave messages at this phone number?
*
Yes
No
Email Address
*
Your answer
What is your role in the East Coast Music Industry? (ie singer / songwriter, musician, composer, manager, booking agent, industry professionals, etc.)
*
Your answer
Do you have income outside of the music industry?
*
Your answer
How can we help? What is your main reason for reaching out for counselling?
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Your answer
Do you have a family doctor / nurse practitioner? If so, who is it?
*
Your answer
Do you have medical insurance?
*
Your answer
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