MAKE A REFERRAL

If you'd like to book a child, youth, adult or family counselling session with one of our practitioners please fill out the form below.

Note: You do not need a formal diagnosis to work with our practitioners and we do not offer formal assessments.

#300 - 1627 Fort St,
Victoria BC
V8R 1B2

info@neurodiversityfamilycentre.com

1 (778) 906-8626

Your Name

Preferred contact method

Age of potential client

I understand that written consent is required from all of the legal guardians of children & youth 18 and under, and that I must submit a custody agreement if applicable

Not Applicable

Yes, I can get consent from all primary caregivers

Getting consent from all primary caregivers will be a problem

Name of practitioner you'd prefer to work with

I would like to work with a practicum student

If you have extended medical coverage, who does it cover?

Registered Clinical Counsellor (RCC)

Registered Social Worker (RSW)

Autism Funding

Not Sure what my coverage is for

Canadian Certified Counsellor

No Coverage