Intake Form

If you would like to proceed with seeking our counselling services, please take a few minutes to fill out our confidential intake form below. Our director will review your information to determine which therapist will be the best match to suit your needs, but in order to facilitate this process, we must receive a intake form. All information provided is kept confidential between the administrative team and designated therapist.

If you are not comfortable submitting your information online, you are welcome to call our office at 604-262-8806 during business hours and our office administrator can help complete the intake form with you over the phone.

"*" indicates required fields

Name*

Contact Information

Can we leave a voice message at this contact number?*
May we email you?*
Address*

Clinical Information

Services Seeking*
Have you previously seen a counsellor at Pacific Coast Counselling (formerly Cedar Springs Counselling)?*
Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)?
Have you ever been prescribed psychiatric medication?
Have you experienced or are you currently experiencing events that you consider to be mentally, emotionally, and/or physically traumatic?
When could you be available for an appointment?*
Do you have extended health insurance coverage for the counselling services?*
Please check with your insurance carrier to see if they cover Registered Clinical Counsellors (RCC), Registered Marriage & Family Therapists (RMFT), or Canadian Certified Counsellors (CCC)
This field is for validation purposes and should be left unchanged.