Self Referral Form

Please fill out the following form to help us understand how we can help you

First Name

Email Address

Last Name

Phone

Reason for seeking services?

Do you have private insurance/extended benefits?

Yes

Please note that this form is not encrypted or confidential. Please do not include sensitive information that you are uncomfortable sharing. This form could be intercepted or disrupted from unauthorized users, therefore your personal information may be read/seen or distributed by someone who unintentionally received your information.

Any questions or concerns regarding Counselling and Support Services’ Privacy and Confidentiality practices may be directed to Tyne Buchy Counselling Collective at tynebuchyrcc@outlook.com, through our contact on here, or via phone.

I have read and understand the above information regarding my confidentiality

Thanks for submitting! One of our counsellors will email you shortly.