Form Writer: Who are you/Relationship to Client?
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I am the Primary Client (Self-Referral)
I am a Family Member of the Client (Self-Referral)
I am a Resolve Team Member/Contractor (Internal)
I am a Community Professional (External)
Form Writer: First name only
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Primary Client/Individual needing the Service: First name only
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Email
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Phone
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To contact you fastest, please include a mobile phone that you are OK w/ us leaving a message on.
(###)
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City, Province/State, Country
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Who is the primary client?
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Adult (25+)
Young Adult (19-Under 25)
Youth (12-Under 19)
Child (0-Under 12)
Couple/Family
Counsellor/Psychotherapist
Student in a Counselling-Related Program
Other Professional
Team/Business/Organization
Gender
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What is/are the age(s) of the client(s) seeking services?
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What financial situation most applies to you?
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ICBC/WCB/CVAP/VAC/FNHA/Other Claim-Related
Insured/Extended health benefits (Out-of-pocket w/ Likely Reimbursement from Benefits Plan to Client)
Uninsured/No extended health (Out-of-Pocket w/ No Reimbursement)
In Need of Sliding Scale (Qualifying or Registered/Certified Counsellors starting at $80-120/hr) (Some Limitations Apply)
In Need of Low-Cost/Affordable Care Program (Graduate Student Counsellor Starting at $60/hr or Sliding Scale) (Subject to Availability, Restrictions and Waitlists May Apply)
Preferred Format/Location?
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Virtual
In Person: Vancouver
In Person: Langley
In Person: Either Location
In Person: Other (Subject to Counsellor Availability)
No Preference (Virtual or In Person is Fine)
What is/are the primary issue(s)/situation(s)/type of support needed?
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Check 2-3 that apply the most to your situation.
Message
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Why are you seeking therapy? (and any additional info/context that you think would be helpful)
Any needs/preferences? Also, please state if you were referred to a particular counsellor (if applicable) AND your top 2-3 additional preferences for counsellors (see About Us->Team).
(i.e. Would like a counsellor who identifies as/specializes with a certain treatment approach; gender, sexual orientation, culture, religion, language, neurodiverse, or lived experience?, e.g. South Asian, LGBTQ+, Poly etc.). Note: We make every effort to match you with the counsellor you prefer, however, we cannot guarantee a match for all preferences, or for particular counsellor, due to changing availability.
How did you hear about us?
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Link from other website
From Friend/Family
From Professional/Organization
Psychology Today
Search Engine (Organic Search)
Search Engine (Clicked on Sponsored Ad)
Social Media
Deliberating Practice Podcast
Professional Referral
Contact info of any professionals involved in treatment/referring you or filling out this form?
