Request for Service

Fill out this form if you are an LGBTQ2+ youth in need of counselling services. 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 in immediate crisis please call Here 24/7 at 1.844.437.3247 or visit the crisis clinic at Grand River Hospital.

Note: This form is transmitted via e-mail and may not be secure.

YesYes, but be discreetNo

TelephoneEmail

Individual CounsellingFamily Counselling

YesNo

If you are in immediate crisis please call Here 24/7 at 1.844.437.3247 or visit the crisis clinic at Grand River Hospital.

YesNo

9am-12pm12pm-3pm3pm-6pm6pm-8pm

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