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Subsidy Intake: $30 per session to see an intern counsellor.
Use this form if you have an annual gross income less than $30,000 and you do not have extended health benefits. Please note if you have extended health benefits, you will need to fill out the $65 or $130 forms. Subsidies are for individuals only, couples and family will need to fill out the $85 or $130 forms.

Personal Information

Contact Information

Is it ok to leave a message on this number?

General Information

What format of counselling would you prefer (check all that apply)
Choose the days and times that you are available for counselling. For in-person sessions, we suggest booking 6-12 appointments ahead with your counsellor, though its optional. Consistency in your appointment day and time is recommned due to limited room availability. You can modify appointments with 48 hour' notice if space is available, otherwise, a virtual session may be necessary.

A note about appointment times:  An option to reduce your waitlist time is to choose morning appointments (8am to 11am) Monday to Friday. By making this time available you will likely get in to see a counsellor sooner.

Presenting concerns, click all that apply:

Financial Information (If you have insurance coverage please fill out the $65 form.)

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. 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.

Methods of Payment
For any online counselling (video or phone ) a credit card, visa/MC debit, 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 session, we also accept cash.


Our Disclaimer:
South Island Counselling is a non-profit organization attempting to alleviate the immense need for affordable mental health services. We will not tolerate any harassment, hostility, or any form of aggression or abuse towards any of the counsellors or staff at any time. If we feel a client or potential client has committed any of the above, we will not provide counselling services.

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