Name*

Email*

Phone #

Preferred Contact Method*
EmailPhoneText

Reason for Counselling*

Demographic*
ChildYouthAdultCoupleFamily

Counsellor Preference

Which type of session would you like?*
In-Person SessionOnline SessionPhone Session

Preferred Appointment Time*
MorningsAfternoonsEveningsWeekends

Payment Preference or Insurance Claim Information*
Privately out of my own pocketReimbursement from my extended medical provider, and am covered to see an RCC or CCC clinicianReimbursement from my extended medical provider, and am covered to see an RSW or RPsych clinicianApproved claim through Crime Victim Assistance ProgramApproved claim through ICBCApproved claim through another insurance provider (please describe and identify any specific needs for clinician credentials for coverage to be approved)

How Did You Find Us?*
Google SearchCounsellingbc.comSocial MediaPersonal Referralreferral by a community organization or professional (doctor, health provider, religious organization, etc.)Other (please specify

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