Subsidy Application

Personal Information

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Contact Information

General Information

On a scale of 1-10 how committed are you to working on these concerns?
What format of counselling would you prefer (check all that apply)
Preferred appointment times and days preferred (check all that apply)
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%) 

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Fee Calculator

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Gross annual income is shown on line 150 of your tax return. South Island Centre 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 Center 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)
Please select an option

Other

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Registered Charity

South Island Centre is a Registered Canadian Charity

#88-724-6999RR0001

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