Referral Request Form

First Name *

Last Name

Optional

Email *

Is this referral for *

You

Friend/loved one

Church member/parishioner

What type of counselling are you looking for? *

Individual

Couple

Family

Do you prefer *

Female Counsellor

Male Counsellor

No Preference

Are you specifically looking for a Christian Counsellor? *

Yes

No

Doesn't Matter

Which area of the GTA would you prefer to see a counsellor in? *

Please provide the specific area (ie. North York, Vaughan, etc.)

Price Range *

Higher End (Usually more experienced therapists)

Mid-Range (You are working and you have some flexibility to pay for counselling)

Sliding fee scale needed (for people who are on fixed incomes, students, single parents, etc.)

Are you looking for a counsellor with a particular area of expertise?

(e.g. anxiety, pornography, abuse, self-esteem, marital issues, pre-marital counselling, etc…)

Is there anything else you would like to mention?

If you do not receive a reply from us within 5 days, please follow up by emailing smcleod@tyndale.ca or calling 416-226-6620, ext. 2123.

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