Please fill out the form below (all fields required):
If you are experiencing a crisis situation or any other urgent matter, please contact the 24/7 Aspiria Clinical Response Centre at 1-877-234-5327 or go to the nearest hospital emergency room.
Who are you?
Are you covered by an Employee Assistance Program?
Are you covered by a Student Assistance Program?
If yes, are you currently enrolled at the institution?
What can we do for you?
I would like to schedule an in-person counselling sessionI would like to schedule a video counselling sessionI would like to schedule an e-counselling sessionI would like to schedule a telephonic counselling session
Please tell us a little more about yourself:
Date of Birth:
If not employed by the company, what relation are you to employee (e.g., spouse, child):
Please provide a brief description of the issue(s) for which you are seeking support:
Have you ever received any support or treatment in the past? If so, briefly explain:
Are you currently experiencing any thoughts of hurting yourself or anyone else, or are you experiencing any violence or abuse? If so, please explain:
Do you have any concerns related to alcohol or drugs? If yes, please explain:
In the past two weeks have you been feeling down or depressed?
In the past two weeks have you been feeling anxious?
May we contact you via your listed email address or phone number and leave a message?
Please compose your first message. Describe your current situation including any important background information. Focus on your main concern and how it is impacting you in terms of your thoughts, feelings, and behaviours. Identify your goals for seeking counselling at this time and what you want to achieve. Please be as descriptive as you wish.
I understand by clicking on this box, I am providing my expressed consent to receive electronic communications including emails about new services and promotions from Aspiria. I understand I may withdraw my consent at any time by emailing Aspiria.