VBT&AF Service Referral Form 

Thank you for completing the service referral form below. Please complete all information below.

We have several programs, each with their individual offerings, timelines and costs. Please read from the description below and let us know which one would best suit your client: 

  1. Free counselling: We offer a yearly free counselling program for Black folks, where we are able to give approximately 30 slots once a year to the applicants with the highest level of need and they are eligible for 10-15 complimentary sessions with a local Black therapist. We aim to open a round approximately each Spring, and the next application round will open in Spring 2025. To be notified when we open our next round, you can sign up to our mailing list here: https://subscribe-can.keela.co/email-subscription. 

  2. Low cost counselling: We offer a low-cost counselling program where folks can receive 15 sessions at a reduced rate of $60-120 based on your capacity to pay. These sessions are all with registered counsellors, although all of them do work virtually and are female-identifying. The link to apply is here: https://docs.google.com/forms/d/e/1FAIpQLSdp3Bh5zKO9XSACKqeujwXIU_-yOct2XsSJDrynQ7cyJ-wTHg/viewform?pli=1. Please note that there is currently a waitlist of approximately 3-6 months, but we would do our best to get the client connected with a counsellor as soon as possible. We do not require any proof of income status. Any folks that apply are automatically accepted, and then we just wait for a counsellor to have the capacity to take them on as a client which typically takes a few months. 

  3. Private practice: All of the Black counsellors we work with have a private practice,so folks can also see these counsellors through their private practice outside of our organizations. This may be a quicker way to get connected with a counsellor if they do not currently have a waitlist, and they may be able to offer reduced cost rates but that would be up to their discretion. To see a full list of the Black counsellors we work with, please go to the bottom of this page: https://vancouverblacktherapyfoundation.com/team.

  4. Patient navigation: We have free patient navigators that are available to support Black folks in British Columbia with accessing PWD supports, filling out applications, locating a therapist, getting connected with various organizations, finding resources (ie. health, food, employment), and other requests. If you are interested in this option, we would provide you with an application form for your client to fill out and then we would pair them with a navigator.

    If you have any questions, please feel free to reach out to us at hello@vancouverblacktherapyfoundation.com . We’re happy to assist and will keep an eye out for your completed application form. If you don't hear back from us within 1–4 business days, please don’t hesitate to send a follow-up email.



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Date of Referral
 *
Is the client aware of and agreeable to this referral?
 *
Name
Please provide your full name
 *
Pronouns
What pronouns do you use?
Practice Name
What is the name of your practice or organization?
Address
Please provide your practice address
Phone Number
Your primary contact number for professional inquiries
Email Address
Please provide your email address
 *
Name
(Please provide the client's full name) *
Pronouns
(What pronouns does the client use?)
Age
(Please provide the clients name?)
Parent/Guardian Information (if under 18)
(Name and contact information for the client's parent/guardian)
Address
(Please provide the clients full mailing address.)
Phone Number
(The client's primary contact number.)
May we call and/or leave them a message?
(Yes/No)
Clear selection
Email Address
(Please provide the client's email address.)
May we email them directly?
(Yes/No)
Clear selection

Please provide us with a detailed description of the reason for referral, including your role in the clients care and what they are looking for


 *
Which of the program(s) listed above is your client interested in ?  *
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