Request Counselling
Complete the form below to request a referral for ongoing counselling sessions covered by AgriCare NL. 

This request form and all personal information submitted through this form are kept private and confidential, and will not be shared with anyone except the intake coordinator and the AgriCare Wellness Counsellor Network, and with the exception of the limits of confidentiality listed below:

- If there is an immediate and serious threat of harm to the individual or another person;
- In the case of neglect or abuse of a child, adult or senior;
- In the case of a court order or subpoena.

For a full list of detailed terms and conditions, please [click here].

This request platform is not for urgent requests. 

> If you are in crisis, please call (866) 327-6701 and ask to speak to a counsellor right away.

> If you are concerned for the safety of yourself or someone else in Newfoundland and Labrador, please call 811 and ask for the Mobile Crisis Unit.

> If this is an emergency, please call 911 or go to the nearest emergency room.
First name, last name *
Preferred method of contact *
Contact phone *
Are we permitted to leave you a voicemail message? *
Contact email *
Are we permitted to send you an email? *
Are you at least 16 years of age? *
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