Huron At Western - Wellness Services
1349 Western Rd.
London  Ontario  N6G 1H3


Phone: (519) 438-7224
Referral Type:
Create a New Referral New Referral

NOTE: If you are in crisis, please contact your local crisis services. If you are residing in Canada, contact Reach Out at 1-866-933-2023. International crisis lines can be found at https://www.opencounseling.com/suicide-hotlines

Thank you for reaching out to Huron's Gender-Based Sexual Violence Advocacy Specialist.

Please provide the following information to request support from the Gender-Based Sexual Violence Advocacy Specialist.
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Referral:
GBSV Self Referral ID
Date: 2025-08-31 11:38
Status: Draft
Attachment(s):
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Hide/ShowPlease tell us about yourself
First Name
Last Name
Preferred Name
Gender
Pronouns
DOB
Select Date Clear Date
Hide/ShowPlease tell us how we can contact you
Primary Phone
Phone
Permission to call?
Phone
Permission to leave a message?
Email
Address
Postal Code
Hide/ShowIntake Form
Year of Study:
Faculty:
FASS
BMOS
Theology
Program of Study:
Animal Ethics and Sustainability Leadership
Jewish Studies
Centre for Global Studies
Management and Organizational Studies
Chinese, Japanese, and East Asian Studies
Philosophy
Economics
Political Science
English and Cultural Studies
Psychology
French Studies
Religion and Theology
Global Great Books
Scholar's Electives
Governance, Leadership, and Ethics
MDiv/MTS/MA
History
Undeclared
Are you a Domestic or International Student?
Domestic
International
Are you currently residing in Ontario?
Yes
No, I am residing in another province
No, I am residing outside of Canada
Are you thinking about or have you recently thought about harming yourself or ending your life?
Yes
No
Do you have any accessibility needs?
Yes
No
If yes, how can I best support you?
What is your appointment availability?
What is your preferred appointment method?
Video Conference
Phone
The Caskey Gilday Wellness Centre
Reason(s) for the referral
Referral Source
 The information you provide is stored within EMHWare and accessible only to Huron's Wellness Counsellors and Gender-Based Sexual Violence Advocacy Specialist. Your privacy is protected and will be discussed further with you in your first appointment.
By sending this form, I allow the agency to contact me
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