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Application Form for Individuals Seeking Funding for Counselling
Thank you for completing this form. You will receive a reply with confirmation to move forward in scheduling an appointment with the counsellor of your choice within 3-5 business days. Funding is available for people living within the Vancouver Island Health Authority.
Your Name
(Required)
First
Last
Your Email Address
(Required)
Enter Email
Confirm Email
Phone
City
These sessions will be for:
Birthing person
Partner of birthing person
Couples counselling
Do you have extended medical coverage to see a Registered Clinical Counselling (RCC) or Registered Social Worker (RSW)?
Yes
No
If you answered yes above, has extended coverage been fully utilised?
Funding is available for up to 5 sessions. Please indicate the amount you are able to contribute to each session. Thank you for choosing the highest amount you are able, this helps support the sustainability and reach of our funding:
*You will pay the amount chosen directly to your counsellor and the counsellor will invoice PPF for the remaining balance.
$100
$75
$50
$25
full scholarship needed
Please check any that apply to your experience:
Trying to conceive
1st Trimester Loss
Recurrent Pregnancy Loss
2nd Trimester Loss
3rd Trimester Loss
Infant Death/SIDS
Postpartum after perinatal loss
Name of counsellor you will be seeing
Clinic phone number
Clinic email
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Why PPF
Get Support
Counselling
Mindfulness
Full Circle Perinatal Care
Resources
Give Support
Donate
Volunteer
Partner With Us
Events
About Us
Our Story
Our Mission
Our Board
Our Partners
In the News