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Service Request Referral Form

Please review our clinical policies prior to completing a referral form if you are requesting our clinical counselling service:

OTHER CLINICAL SUPPORT: Our mission is to offer support to individuals navigating grief or experiencing end-of-life palliative care. If you or your client is currently connected to a mental health professional, we respectfully ask that you refrain from initiating a referral. Instead, we encourage you to maintain your ongoing relationship with your current mental health provider and allow space for continued support.

SUBSTANCE USE: In our experience, we have found that substance abuse must be dealt with before grief counselling can be effective. Therefore, we request that individuals struggling with substance addiction should have at least six months of sobriety before completing a referral for grief support.

EMPLOYEE BENEFITS: The Campbell River Hospice Society operates as a non-profit organization, dependent on community donations to sustain our specialized services provided to the community free of charge. If you have employee benefits for counselling services, we ask that you explore that option.

All information shared with us remains private and confidential. If you are completing this form on behalf of the client, please ensure the individual has provided consent. 


Referral Form

Client Information

Submitters Information
If completed on clients behalf

Who should we contact?

Thanks for submitting!

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