Counselling Application Form

Your Name*

Date of Birth*

Your Email*

Home Phone Number*

Cell Phone Number

Business Phone Number*

Your Address*

Family Physician Name*

Family Physician Phone Number*

Next of Kin Name*

Next of Kin Phone Number*

Referral Source

I am over 18 years of age. I am currently living in English Canada, or I am a permanent resident of English Canada. In the past year I have not threatened or planned suicide or homicide, engaged in self-harming behavior such as cutting or burning, had a mental health emergency, used drugs other than marijuana illegally, had a sexual relationship with a minor (unless the authorities already know about it), been involved in domestic violence as abuser or victim, or been involved in violent or organized crime. I do not work in law enforcement or in any occupation that requires me to be armed. I am aware that my counsellor does not do reports or write letters for custody. I agree that, should I be involved in legal proceedings, neither I nor my lawyer(s), nor anyone else acting on my behalf will call on my therapist to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested unless it is by mutual consent.

I agree to pay for each session by Interac 48 hours in advance if it is in the office or 24 hours in advance if it is online, unless another arrangement has been made ahead of time.

I live in British Columbia OR (use drop down below). While I do not anticipate that I will have a mental health crisis, I have prepared a crisis reference list, which I keep for ready reference. The list should include 911 and the phone numbers of the local crisis line and/or other local emergency service, any clinic where you are enrolled, any friends or relatives who might be able to help, a local taxi service if there is one, and the address of the nearest hospital emergency entrance. I am attaching this list along with this form to the email message (or mailing it if mailing a hardcopy of the form).

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