Request for Service
Online Intake Form for LGBTQ+ Clients
Fill out this form to access individual/family counselling as a member of the LGBTQ+ community. Feel free to call us at 519.884.0000 x222 with any questions.
Our counselling services are only available in Waterloo Region, Ontario, Canada.
If you are elsewhere in Ontario please visit Ontario211 to find local resources.
Please be advised that it can take 2-4 business days for an intake worker to contact you. If you are in immediate crisis please call 519.745.1166 or visit the crisis clinic at Grand River Hospital.
Please use this form only if you identify as a member of the LGBTQ+ community. Otherwise, or if you have questions, please contact our Intake team at 519.884.0000 x222 or email@example.com.
Note: This form is transmitted via e-mail and may not be secure.