PEI 2SLGBTQIA+ Mental Health Initiative

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 your preferred therapist(s) as soon as there is a spot available for you.

Please make sure to read our therapists’ bios here before completing this form.

If you have any questions that have not been answered in the information brochure linked above, please contact us 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

(###)

###

####

I am applying for

Please select ONE (please submit a new form to apply for more than one type of therapy)

Individual Therapy

Relationship Therapy

Family Therapy

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 age group(s) do you fit in?

If applying for relationship or family sessions, please select all applicable options.

12-15

16-18

19-60

61+

Do you currently reside in PEI?

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.