Are you a front-line worker in the Indigenous sector in Montreal?

GENERAL INFORMATION

Full name *

Email *

Phone number *

Are you an Indigenous person? *

Yes
No

Indicating that you are a non-Indigenous person will not impact your eligibility to receive mental health support for frontline workers.

Are you a member of a First Nation with recognized status, or a member of one of the Inuit or Métis communities recognized by a land claim organization? *

Yes
No

This will help us pre-verify your eligibility to other mental health related services.

What identification document do you have? *

Indian Status Card
Inuit Beneficiary Card
Métis Citizenship Card

Do you work for a frontline program or organization in the Indigenous sector? *

Yes
No

A frontline program or organization directly assists community members.

Where do you work? *

Other *

Please specify where you work.

What is your professional title? *

Do you have personal or work insurance that covers mental health sessions with a therapist? *

Yes
No

If yes, which ones? *

Indicate the name of your insurance provider.

Have you already used the sessions allocated by your insurance companies? *

Explain.

If you would like to give us more details about your insurance, please do so below. *

Explain.

THERAPY PREFERENCES

What language(s) do you prefer to receive therapy in?

English
French
Can be in English or in French
Other

Other *

Please specify language

In whichever way you feel most comfortable, please write down your identities, social locators, and any other relevant information that may be applicable (race, ethnicity, faith, gender, sexuality, disability, communities, etc)

We will use this information to match you with the most relevant person to support you.

Would you like to receive therapy online, or in-person? *

Online
In person
No preference

Please provide the neighbourhood(s) that you would like to receive therapy in. *

Please note that providing a flexibility of options may speed up the wait time for accessing therapy. ocation(s)

Do you have any specific preferences for a mental health worker? (i.e., gender, spirituality, ethnicity, sexuality, etc).

Please indicate your level of preferences for the following types of mental health support options

Please indicate the number of sessions you would like to have *

1-5 sessions
5-10 sessions
10+ sessions

Currently, we can only cover up to 10 sessions per individual. Prolongations are possible depending on available budgets and the influx of requests.

Without going into detail, please write down a short description as to why you are looking for mental health support. *

Examples may include: Burnout, stress, anxiety, traumatic event, grief, isolation, etc

Please select your availabilities