Subsidy Application

Personal Information

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Contact Information

General Information

What format of counselling would you prefer (check all that apply)
Choose the days and times that you are available for counselling. Please choose carefully as these times/days will be used to set up your future appointments.
Presenting concerns, click all that apply:

Financial Information (proof of income is required in the form of a tax assessment. The counselling rate will be calculated by multiplying Gross Annual Income by 0.1%) 

Fee Calculator

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Gross annual income is shown on line 150 of your tax return. South Island Counselling reserves the right to request formal documentation for proof of income. Examples of proof of income are tax returns, pay stubs, disability insurance, letter from employer, pension documents, or unemployment documents. The applicants subsidy form will not be processed until proof of income is sent to info@southislandcentre.ca If the applicant is under the age of 18, parent(s) proof of income will be required.

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Subsidy is granted only when funding is available. The subsidized rate is valid for up to 12 sessions. All subsidy applications are subject to approval by South Island Counselling Management. Due to the limited availability of subsidies, please also explore other funding sources and list them below. Third-party sources must be exhausted before subsidized rates takes effect. Please include additional notes and documents if there are other extraordinary circumstances that affect your ability to pay. All information will be kept strictly confidential.

Extended Health Coverage

Extended Health Coverage (please check appropriate box, if yes please fill out Plan Name below)
Select an option

Methods of Payment

For any online counselling (video or phone) a credit card, visa/MC debit, google pay or apple pay will be required for payments. Your payment method must be set up in the Jane App system before your first appointment. All payments will then be processed at the end of each counselling session by your counsellor. We do not accept e-transfers. 

For in-person sessions we accept credit card, debit card, apple pay, google pay or cheque. 

Other

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