BCG Subsidy Application Form

Important Information About Our Subsidy Program

Before you complete this subsidy application form, please note that subsidies are granted only when funding is available. Generally, the subsidized rate is valid for up to 10 sessions or 5 months (whichever comes first). All subsidy applications and renewals are subject to approval by BCG Management.

Please Note

Due to the limited availability of our subsidies, we encourage you to explore other available funding sources. If any are accessible to you, please include them as other funding sources in your application form. All information will be kept strictly confidential.

If you’re a new client, we recommend contacting our Intake Coordinator at intake@counsellinggroup.org or at 604-430-1303 (ext. 1) while your subsidy application is being processed. This will allow us to help you further as there may be a wait to see your desired therapist.

Application Form

All fields indicated with a red star (*) are required.

Name *

If you are applying on behalf of your dependent(s), please also include their name(s) in brackets.

Email *

name@email-address.ca

Phone *

555-555-1234

Household Size *

The number of people living in the same dwelling sharing common financial resources.

Household Income *

The combined gross annual income of everyone in the same household (line 15000 of tax return)

Extended Health Care Plan / Employee Assistance Program (if applicable)

Indicate plan name, type of credentials it covers (Registered Clinical Counsellor or Psychologist) and amount of coverage.

Other Third-party Funding Sources (if applicable)

Indicate the name(s) of the third-party funder(s), such as family member, church, or social service agency, and the amount of coverage.

Additional Information

Date

Please leave this field empty.