Service Request Form

Moving Forward Family Services (MFFS) is a mentorship agency – providing counselling and social work practice opportunities to interns and new graduates beginning private practice. We receive funding for clinical supervision (supervisors who support interns and new graduates) and these supervisors in turn oversees an agency that has over 275 part-time counsellors, social workers and interns on post-secondary practicums, providing support to some of our most vulnerable communities. Community support also comes by way of donated space. This unique model allows the agency to offer timely, affordable (including free for those with no income) counselling and support without being bound by restrictions based on gender, age, geography or presenting issues. It also allows MFFS to complement existing services (as opposed to competing with them for the same pools of traditional funding) thus reducing pressures on these services. MFFS is committed to building and contributing to healthy, healing communities. While we keep our costs low, we do not receive any funding from traditional sources (Fraser Health, Vancouver Coastal, MCFD, Corrections, School Districts) that traditionally fund counselling in the province; therefore we need to explore fees from clients as a way to cover our operating expenses

REFERRAL / SELF-REFERRAL

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 https://movingforward.help/get-started under the 'Help Directory' Tab

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

https://wellnesstogether.ca/en-CA

Other resources: https://www.heretohelp.bc.ca/get-help

First and Last Name of Person Seeking Services

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

Name of Parent(s)/Guardian(s) if above is under 13 (*See additional information below for services for children)

*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.

Making a false claim around guardianship may adversely impact current or future custody/family court matters

Date of Birth (Month/Day/Year)

Age

Identified Gender

Phone Number

E-mail

City of residence

Province

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

Street address

Reason for Seeking Counselling / Presenting Issue (please try to provide as much detail as you are comfortable with, as it allows our supervisors to find the best match)

What are you goals for counselling? To make the most effective use of your time in a session, it is important to establish some goals - if you are not able to do that now, please consider it between now and when you attend your first session

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/$75). Note these services are online or by phone - if looking for in-person services or wanting to use insurance, the registered therapists will charge $100-$130 individual and $150-$175 for couples/families. If looking for in-person services our site is in Newton, Surrey; you may also wish to review options found on Pychology Today website or the registry on the BCACC website
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). These services are online or in-person
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). These services are online or in-person
You have pending 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. Our interns do not do assessments nor thorough reports that courts may require

Counselling Service Options Low income is based on Gov of Canada figures https://www.canada.ca/en/employment-social-development/services/foreign-workers/caregiver/financial-ability.html

Online or phone services with intern.Please note that while our students on practicum are insured and supervised, they are trainees; clients access our services as they have not been able to access publicly funded services and cannot afford traditional private therapy rates. As trainees, our interns are not in a position to diagnose or assess, nor offer any clinical opinions. $20 individual /$35 couples or family - service with an intern on practicum - online or phone only (Note: you cannot use insurance for this service). NOTE: As our services are provided by students and newer counsellors, be advised that anyone with complex needs (Complex trauma, PTSD, BPD, Schizophrenia) may be better supported through other resources in the community. Appointments are Monday to Friday, between 9 am to 5 pm. Limited weekend or evening. Please note that while our students on practicum are insured and supervised, they are trainees; clients access our services as they have not been able to access publicly funded services and cannot afford traditional private therapy rates. As trainees, our interns are not in a position to diagnose or assess, nor offer any clinical opinions.

3-4 weeks wait. Health Authorities, Corrections, MCFD and School Districts are responsible for public-funded counselling (they also fund non-profits to provide public funded services) - prior to contacting us, please contact these resources (we are not funded by these government groups). Location: Canada-wide. Online or phone only at this time (due to pandemic) - no in-person services at this time. For couples counselling, each person will be seen individually for assessment before couples counselling sessions are provided. While service is available Canada-wide, be advised we follow regulations related to counselling practices within British Columbia. Languages: English. NOTE: Once an appointment is booked, we require a minimum 24-hours notice for cancellation - otherwise missed appointment fees may be charged. Also note that interns are expected by their schools to see a diverse range of clients - and therefore can only offer short-term services. Maximum # of sessions with one intern: 12. As part of their professional development/studies, these interns are required to audio/video some of their sessions and discuss their cases with supervisors and colleagues.

'Pay what you can' Service with an intern - online or phone only. (Note: If you have full-time employment you are not eligible for this service). NOTE: As our services are provided by students and newer counsellors, be advised that anyone with complex needs (Complex trauma, PTSD, BPD, Schizophrenia) may be better supported through other resources in the community. Appointments are Monday to Friday, between 9 am to 5 pm, no evening or weekend appointments. If you have limited availability for an appointment you are not eligible for this service. Please note that while our students on practicum are insured and supervised, they are trainees; clients access our services as they have not been able to access publicly funded services and cannot afford traditional private therapy rates. As trainees, our interns are not in a position to diagnose or assess, nor offer any clinical opinions.

6-8 weeks wait. Health Authorities, Corrections, MCFD and School Districts are responsible for public-funded counselling (they also fund non-profits to provide public funded services) - prior to contacting us, please contact these resources (we are not funded by these government groups). Services with new interns with limited experience. Location: Canada-wide. Online or phone only at this time (due to pandemic) - no in-person services. Proof of low income may be required. For couples counselling, each person will be seen individually for assessment before couples counselling sessions are provided. Note: sessions are 45-55 minutes long, and offered once per week. Up to 4 free sessions for those with NO INCOME, with potential to extend in consultation with Supervisor. If you have income you are expected to 'pay what you can.' While service is available Canada-wide, be advised we follow regulations related to counselling practices within British Columbia. Languages: English only. Once an appointment is booked, we require a minimum 24-hours notice for cancellation - otherwise missed appointment fees may be charged. Two missed appointments may result in cancellation of services. Also note that interns are expected by their schools to see a diverse range of clients - and therefore can only offer short-term services. Maximum # of sessions with one intern: 12. As part of their professional development/studies, these interns are required to audio/video some of their sessions and discuss their cases with supervisors and colleagues. To ensure we can see new clients in a timely fashion, the supervisor will review the file regularly - during such reviews, other options (groups, moving sessions to biweekly, etc.) would be considered. Note multiple (two) missed sessions may result in discontinuation of service.d

I have coverage. In-person (Surrey) and online with a private registered therapist. NOTE: Private counsellors are not employees of MFFS - we simply refer clients to these private therapists

1 week wait. Location: Canada-wide. Online or in-person. While service is available Canada-wide, be advised we follow regulations related to counselling practices within British Columbia. Once an appointment is booked, the private counsellor requires a minimum 24-hours notice for cancellation - otherwise missed appointment fees may be charged. Approximately $100-130 for individual ($150-$225 couples/families) with a Registered Therapist (and you can discuss with that private therapist what rate would be after insurance runs out). If counselling is covered by ICBC, WCB or your extended health/insurance, then a private registered therapist will follow up with you. Note that you need to confirm with your ICBC claims adjuster, WCB case manager, Human Resources Manager/Insurance company representative, etc. to clarify what type of counselling is covered (some may only cover counselling by registered counsellors, registered psychologists or registered social workers) and whether that coverage allows for direct billing or if you would first need to pay and then submit the receipts for reimbursement. Note that our basic MSP (Medical Services Plan) in BC does not cover counselling.

I do not have coverage but am a high income earner. In-person (Surrey) and online.

I am low income and requesting: $50 individual / $75 couples or family with a private Clinical Counsellor. Online only - in-person option fees are higher

1 week wait. Location: Canada-wide. Note: Online or phone. While service is available Canada-wide, be advised we follow regulations related to counselling practices within British Columbia. Once an appointment is booked, the private counsellor requires a minimum 24-hours notice for cancellation - otherwise missed appointment fees may be charged. Please note: Clients being referred by Moving Forward Family Services to private registered therapists are eligible for a reduced rate for the first 4 counselling sessions. Rates MAY be adjusted on the 5th session (client can discuss this with the private counsellor). Clients who are not low income and/or have insurance coverage do not qualify for these rates. In order to prevent misuse of this resource (that low fee services are only offered to low income clients without insurance), the therapists will note on any receipts that are requested that the fees charged were premised on client reporting they were low income, and thus the receipt should not be processed for any subsequent insurance claims. Additionally, receipts will not include the counsellor's registration number, office address (as these are typically required by an insurance carrier and not be signed). Such measures ensure the resource is not being exploited.

Mindfulness Based Somatic Therapy (MBST) Trauma Counselling for Adults & Adolescents HEALING BODY, MIND & SPIRIT with Clinical Counsellor for $95

1 week wait. Location: Canada-wide. Note: Primarily online or phone only at this time (due to pandemic). Some of these counsellors may be willing to meet in-person (Surrey, BC, Burnaby, BC), but fees may be higher for in-person services. While service is available Canada-wide, be advised we follow regulations related to counselling practices within British Columbia. Once an appointment is booked, the private counsellor requires a minimum 24-hours notice for cancellation - otherwise missed appointment fees may be charged. Please note: Clients being referred by Moving Forward Family Services to private registered therapists are eligible for a reduced rate only if they are low income and have no insurance coverage. Clients who are not low income and/or have insurance coverage do not qualify for these rates and may be charged more (client can discuss with the therapist). In order to prevent misuse of this resource (that low fee services are only offered to low income clients without insurance), the therapists will note on any receipts that are requested that the fees charged were premised on client reporting they were low income, and thus the receipt should not be processed for any subsequent insurance claims. Additionally, receipts will not include the counsellor's registration number, office address (as these are typically required by an insurance carrier and not be signed). Such measures ensure the resource is not being exploited.

Coaching, Seniors Support Check-in Calls or Group Option only. These are in English only

Options listed below. If directed to attend counselling for court, probation, Ministry (MCFD) or any other third party source, these programs would not meet counselling requirements (in which case you may wish to consider a combination of one of the counselling options above and one of the programs below)

Other Options: One-on-One Coaching Programs (note that Coaching Programs are NOT counselling, they are psycho-education support and coaching. These programs are for youth and adults 16+ and facilitated in English).

Free Seniors Support Services (phone calls) from an Intern/Volunteer. In English

Weekly phone calls (5-20 minutes or longer) consisting of a check-in and a facilitated self-care activity

Free 12-session Individual CBT Coaching with a volunteer or intern over phone or online. Note this is coaching/education, not therapy. English only. Also you must have internet access to review videos

Free 8-session Healthy Relationships Coaching with a volunteer or intern. Note this is coaching/education, not therapy. English only. Also you must have internet access to review videos

Minimal wait. Location: Canada-wide. Note: this is a coaching program, based on a curriculum, facilitated by volunteers or interns; if wanting to do in-depth work, consider one of the above options in addition to this option. Not suitable if you wish to do intensive therapeutic work This program provides one-to-one coaching with participants with a focus on skills for healthy relationships with an intimate partner. This is NOT a couples counselling program nor is it an anger management program for someone charged with abuse against an intimate partner but rather a program for individuals interested in learning skills to improve their intimate relationships. These are intended to be individual psycho-educational coaching sessions. Please note that our counselling services are not funded by public services responsible for mental health and addiction services (for example Health Authorities, Ministry for Children and Family Development, School Districts and Corrections) and thus we operate on cost recovery. While this program is 'pay what you can' including free, any contribution you can make is greatly appreciated and allows us to continue to offer low barrier services across Canada. Note multiple (two) missed sessions may result in discontinuation of service.

Free 6-session Mindfulness Coaching Program. Also you must have internet access to review videos. In English.

Minimal wait. Location: Canada-wide. 6-session individual Mindfulness Coaching with an intern or volunteer online or over phone. Note this is psycho-educational coaching, not therapy. English only. The goal of this program is to provide mindfulness-based strategies and skills that can contribute to mental wellness in day-to-day life. Note multiple (two) missed sessions may result in discontinuation of service..

HOW DID YOU HEAR ABOUT OUR SERVICES?

Referred by (if applicable) Name, agency, email, phone - and any additional information you wish to provide

TO REFERRAL AGENCY (if applicable)

Please ensure you have advised your client of the various services (and fees) and advise client that multiple missed missed appointments may result in missed appointment fees and/or discontinuation of services. Note as well we will make up to two efforts to contact client and if client does not reply back we will close referral. In the rare instance that client claims no one has called them within the wait times listed above, ask them to call 778-321-3054. Furthermore, we ask you to continue to look for additional resources for your referred clients in addition to the services we may be able to offer. If you are referring client for 'pay what you can' you should first explore funded services offered by MCFD, Health Authority, Corrections and School Districts. Please note if referring to interns: that while our students on practicum are insured and supervised, they are trainees - clients access our services as they have not been able to access publicly funded services and cannot afford traditional private therapy rates. As trainees, our interns are not in a position to diagnose or assess, nor offer any clinical opinions.

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 counsellor@movingforwardfamilyservices.com 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

Client Acknowledgement

Please check acknowledgement

*** I acknowledge I am (or client is) low income and therefore am requesting one of the services listed above. I understand I may be required to provide proof of low income *** I also understand if choosing a service with an intern that they would have limited prior experience and cannot offer specialized services - and if choosing the option with an intern that I acknowledge that I have not been able to access services through the agencies responsible for publicly funded counselling (for example Health Authorities, MCFD, School Districts, Corrections) and that such services have a maximum number of sessions (outlined above. Furthermore, I understand that if opting for service with interns that they do not conduct psychological assessment and will not provide detailed letters for court/probation/social worker. *** I acknowledge that once an appointment is made, I will make every effort to attend and provide a minimum of 24-hours advance notice if I cannot attend, and that missed appointment fees may be charged and/or discontinuation of services for multiple misses *** I understand that while services are offered across Canada, MFFS is based in British Columbia, Canada, and follows provincial laws related to service agencies.

If you chose 'Pay What You Can' - approximately how much can you pay per session? Note we can only offer up to 4 free sessions for '0' dollars and you will be required to provide proof of no income to access this service. If you are being referred please check with your case worker about funding for your counselling services

Any preferred days/times for services? Note there are limited weekend/evening services for low/no fee options

*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 counsellor@movingforwardfamilyservices.com or at 778-321-3054

Making a false claim around guardianship may adversely impact current or future custody/family court matters

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