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MIAG Centre for Diverse Women & Families 

Mental Health Counselling Intake Form


*Please be advised that our staff member, Solinas, may need to follow-up with a phone call and/or email to collect more information necessary for the referral process.*

Referral Counselling Form

NOTE: Please be advised that there may be some limitations regarding the counsellor’s language and the format of sessions (online or in-person) depending on availability. We will contact you to discuss available options. I understood and agree to this.

Disclaimer:

MIAG intake line is not equipped as a crisis response unit. If you are in a mental health crisis, please call 988. 

Also, the counsellors we work with cannot provide crisis nor emergency services. They CANNOT support clients with active psychosis. Please call 911 for an emergency or 988 for crisis. I understood and agree to this disclaimer.