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PAFNW
Counselling services for families of MMIWG/Covid19 is our focus. (Referral to other community resources)
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* Indicates required question
Email
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Your email
First Name, Last Name
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Your answer
What is your Indigenous Nation and/or Band?
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Your answer
City
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Your answer
Phone #
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Your answer
Postal Code
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Your answer
Gender
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Female
Male
Other:
Required
Age range
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19-30
31-50
51-70
70+
Have you or your family been impacted by the MMIWG?
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yes
No
Other:
Required
Have you or your family been impacted by Covid 19?
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Yes
No
Other:
Required
What health or mental health issues are you experiencing?
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Depression
Anxiety
Suicidal Thoughts
Residential School Trauma
Intergenerational Residential School Trauma. Did any family member attend residential school?
60's Scoop (adopted out, fostered, permanent care)
Substance Use - Alcohol, Opioids, Opioid Agnostic Therapy (OAT), Heroine, Cocaine, tobacco
Medications, if yes what are they?
Chronic pain
Diabetes
None
Other:
Required
Which device or software do you prefer to have your counselling sessions on? Please check a box.
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Zoom
Phone/Cell
Face-Time
Required
PAFNW counselling services will create a wait list. Be safe and take good care. Please add any additional comments.
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Your answer
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