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

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

If you are a referral agency, consider sponsoring your low income/no income client's therapy. Email to learn more about how your organization can sponsor a client's therapy

*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.

Your information will be encrypted.