Elsewhere Request for Support Form
Who should use this form? 
If you would like to access counselling or enrol in the Elsewhere group therapy program, please complete this form.

What happens after I submit? 
Once your application has been assessed, you will receive a response via email explaining the next steps. 

When will I hear back?
Usually within 7 business days, though this may vary depending on how busy things are. 
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What is your full name? *
Please include your first and last name
What is your email address? *
What is your age? *
Are you...?  *
What is your sexual orientation? *
What country do you live in? *
Please include your cultural background (if the two differ) eg. Malaysian in Canada
Are you interested in: *
Are you able to self-fund any of your therapy?  *
1:1 counselling is $90 USD per session.
The 6-week group therapy program (including 2 x 1:1 sessions) is $350 USD. 

There is an option to make a partial contribution towards your therapy (ie. pay what you can); however, these spots are limited. 

Please note that if you require a sponsorship to cover 100% of your therapy costs, you may be on the waitlist for a long time.
Which of the following best represents you? *
Which of the following have you experienced?  *
Tick as many as applicable
Required
How did you find us? *
Required
Please tell me about yourself, your current situation, and what kind of support you are looking for. *
Submit
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