Waterloo Region 24/7 Crisis Line: 1-844-437-3247 | Call Us: 519-669-8651 | info@woolwichcounselling.org

Contact Information

Monday-Thursday: 9:30 a.m. to 8 p.m.
Reception hours vary.

Phone: 519-669-8651

Fax: 519-669-0980

Email: info@woolwichcounselling.org

Address: 65 Memorial Ave, Elmira, Ontario N3B 2R9
Parking is available at the centre.



Pre-Enrollment Form

We are glad you are reaching out to us and look forward to connecting with you.

If you are in crisis, feeling unsafe, or worried you might hurt yourself or others, contact Here 24/7 at 1.844.437.3247 or visit the nearest hospital emergency room. For emergencies, call 911.

Please use the form below to provide the information of the individual to be contacted.

Once you submit the form, we will contact you at the earliest possible time to determine how we can support you. 

Only submit one copy of this form, even if completing for multiple individuals.

All information submitted will be kept confidential.

    Please enter your full name.

    Please enter your phone number.


    Please select either 'Yes' or 'No'

    Please enter your email address.

    I consent.

    SelfCoupleFamilyChild(ren) - Ages 4-12Youth - Ages 12-18Group ProgramsWorkshop InformationYour client or referral

    Check all that apply

    Additional Group Programs Information

    Please enter the name of the group

    Additional Workshop Information

    Please enter the name of the workshop

    Additional Client or Referral Information

    Please enter the name of the referrer

    Please enter the contact number of the referrer


    Please select either 'Yes' or 'No'

    A copy of client consent to be faxed to: 519-669-0980