CREATIVE WELLBEING

First Time Application Form

Please complete this form to refer yourself to our program. You will be contacted to schedule a free 15-minute consultation with one of our therapists as soon as there is a spot available for you.

If you have any questions that have not been answered on the main Creative Wellbeing page, please contact Nicole at admin@ourlandingplace.com

Name

Please provide the name you would like us to use for you. This can be different than your legal name.

First Name

Last Name

Pronouns (optional)

Phone

(###)

###

####

Please provide a brief description of your presenting concerns.

This will help us match you with a therapist and ensure we are best serving you and the community.

Are there any specific identities or experiences you would prefer your counsellor to have (e.g. gender, sexuality, ethnicity or cultural background, language, religious background, disability, age etc.)

Which area(s) of arts and culture do you work in? (e.g. musician, visual artist, sound technician, curator etc.)

Are you 19+?

Please note, this funding is only available for those aged 19+.

Yes

Do you currently reside in PEI?

Yes

Do you have coverage for mental health services? (e.g. Extended Health Benefits Plan)

Those with coverage are still eligible for this program, and will be asked to use their coverage first before using up their allocated hours.

Yes

How did you learn about the program?

Please make sure to add admin@ourlandingplace.com to your email's safe senders list and check your junk/spam folder to ensure you don't miss an email from us. We will connect with you from this email address to offer you a spot in the program.