Self Referral Form

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

Do you have private insurance/extended benefits?

Before submitting please read and consent to the following information. This service is not guaranteed to be confidential using an encrypted service. If you choose to self-refer through this service, you understand and acknowledge that your confidentiality and privacy will be respected to the best of the abilities given the services being used (i.e. it will not be shared purposefully or intentionally). However, you understand that this service 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. Should you feel uncomfortable using this form to self-refer, you can reach out to Tyne Buchy through the contact form on this site, via personal email tynebuchy@hotmail.com or through phone at (778) 906-8633. Please do not share any information that you are uncomfortable sharing, or feel is too sensitive to share. Use of this form IS NOT REQUIRED to receive services but is intended to streamline procedure and facilitate entry into counselling services for you as the client.  

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

Thanks for submitting!