Service Request Form

Moving Forward Family Services

Please correct the errors described below.


Please be advised that there are potential risks and benefits associated with any form of therapy and positive results from therapy cannot be guaranteed or assured.

Do You require URGENT care? Health Authorities, provincial Ministries and School Districts provide urgent and short-term care in British Columbia. Consider accessing these services if in need of urgent care: (while some services offer drop-in, if possible, try calling first as hours may change due to Covid-19). For a list of urgent care services please visit the resources page of our website at

NOTE: We are not funded by Health Authorities, MCFD, School Districts or Corrections - government ministries that are responsible for publicly funded counselling - therefore we can only offer a limited number of free sessions (up to 4) - and these are reserved for clients who are not employed.

Do you want to connect with someone today? Call Wellness Together

Phone. Call 1-866-585-0445 (Adults) or 1-888-668-6810 (Youth)Text (SMS). Text WELLNESS to 741741 (Adults) or 686868 (Youth) to connect with a trained crisis responder for support

NOTE: As our services are provided by students and newer counsellors, be advised that anyone with complex needs may be better supported through other resources in the community

By completing this referral / self-referral the above client commits to attending appointments as scheduled and understands that multiple missed appointments may result in missed appointment fees and/or discontinuation of services

While service is available Canada-wide, be advised we follow regulations related to counselling practices within British Columbia

Why do we ask for fees?

While we receive numerous referrals from Health Authority sites, MCFD, Probation and Schools (who are responsible for publicly funded mental health and addiction counselling/psycho-education services), we are not funded by any of these groups - thus rely on fees to help cover our operating costs. There is benefit in not being funded by such sources - in that we do not have to limit who we serve based on age, identified gender, presenting issue, geography, bureaucracy yet in order to remain sustainable, we need to ask for fees ... therefore if you are looking for free services please contact those government service providers.

We also ask you to consider the fees as an investment in your own well-being in addition to helping sustain our services.

At the same time we recognize the private system is financially out of reach for most who need it.

We therefore see ourselves as a hybrid - taking the best of both systems in efforts to provide a low barrier, quality and sustainable service for our diverse communities.

What option is best?

  • You are low income, do not have insurance and may need longer-term therapy: consider services with a private, registered therapist ($50/$65)
  • You are low income and cannot afford the fees for a private registered therapist: consider short-term services (up to 12 sessions) with an intern ($20/$35) - the intern as part of their school requires that they see a diverse range of clients, so cannot offer longer-term therapy (however can facilitate a transfer to another intern once the 12 sessions are completed)
  • You have no income and cannot afford a private registered therapist: consider short-term services (up to 12 sessions) with an intern for 'pay what you can' - the intern as part of their school requires that they see a diverse range of clients, so cannot offer longer-term therapy (however can facilitate a transfer to another intern once the 12 sessions are completed)
  • You have pending criminal court or family court matters - consider working with more experienced counsellors (private counsellors) compared to interns (students). Note that fees will be charged for any letters or copies of notes requested

If you are a referral agency, consider sponsoring your low income/no income client's therapy as we are not funded by the ministries responsible for publicly funded counselling (Health Authorities, MCFD, Education through School District, Corrections). Email to learn more about how your organization can sponsor a client's therapy. You can also donate to support our low barrier services and receive a taxable receipt

*By submitting this form I acknowledge I have reviewed the "For Clients" and/or "For Service Providers" tab (if applicable) found on the website

Our Privacy and Confidentiality Policies: As part of our work together, we will collect personal information about you for the purposes of providing consultation, counselling or referral services. This information may include current concerns, relevant history and family information. Such information will be kept safely stored in a secured location. Relevant information may be shared between counsellors and counselling supervisors for the purpose of professional consultation and with administrative staff as related to managing files. While your information is confidential, there are legal exceptions to confidentiality. While rare, these situations include: where such information is required to assess the possibility of/to prevent a life-threatening situation, whether it pertains to a client or a third party; when there is concern that a client may not have the capacity to identify when a situation is harmful; when there is evidence or suspicion that a child is, or may be, in need of protection; for the purpose of a legal proceeding, court order, or other legal requirement. Clients may be given supervised access to their file if requested. The client has the right to receive explanation of any information in the file, and to include documentation regarding any information they may feel is inaccurate. Any questions or concerns regarding Counselling and Support Services’ Privacy and Confidentiality practices may be directed to Clinic Supervisor Gary Thandi, MSW RSW at or at 778-321-3054

*Services for Children 12 Years of Age and Under

Services for children 12 years of age and under require consent from any and all legal guardians.

In cases where parents are separated or divorced, court rulings regarding custody or guardianship may limit the rights of one parent to take a child to see a counsellor without the consent of the other.
In completing this referral, you are agreeing that you either have the agreement of the other parent to bring your child to therapy or that you have the legal right to bring your child for therapy without the other parent’s consent.

Please note:
● We will not put the child(ren) in positions where they feel they have to speak out against one of their caregivers.
● We do not provide assessments for Family Court
● We will not provide letters that are critical of the other caregiver’s parenting.
By submitting this referral request for counselling for a child, you understand and accept the above information and confirm that you are legally entitled to provide consent for child therapy.

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