INDIGIQUEER CHILD AND YOUTH MENTAL HEALTH INITIATIVE

Application Form

Please complete this form to refer yourself to our program.

Please note, due to program capacity, at this time we only have funding remaining for individual sessions for folks ages 13+.

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.

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)

Email

Phone

(###)

###

####

Please provide a brief description of your presenting concerns.

This will help us ensure we are best serving you and the community.

Which province do you live in?

British Columbia

Alberta

Please select the age of who will be participating in sessions.

13-15 years old

16-18 years old

19+ years old

Please make sure to add mackenzie@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 one of these email addresses to offer you a spot in the program.