Counselling Service Request Form

Full name of parent or guardian if the person seeking services is under 13 years of age.

First Name

Last Name

Phone Number

E-Mail Address

Street Address

City

Province

Postal Code

Age

Date of Birth

Identified Gender

Why are you seeking counselling? Please try to provide as much detail as you are comfortable with, as it allows our supervisors to find the best match.

COUNSELLING SERVICE OPTIONS - Please choose either services with Intern (Student on a practicum) or Registered Therapist.

Health Authorities, Education, Corrections and Ministry of Children and Family Development are responsible for publicly-funded counselling, and we do not receive any funding from those sources. We therefore operate on cost recovery. Because we are not funded by government sectors responsible for publicly-funded counselling, we can only offer up to 4 free sessions with an intern to clients who are unemployed.

Select any of the following if an appointment with an intern best suits your needs. Note: if you are a high income earner or have benefits, you are not eligible for services with an intern. Please only choose one counselling option (with intern or with a private registered therapist). You cannot use insurance coverage for this service. Select any of the following if an appointment with a Private Clinical Counsellor or Private Registered Therapist best suits your needs Please only choose one counselling option (with intern or with a private registered therapist). Please only select one of the options: services with intern, or services with registered therapists

Individual session: Online or phone with an intern. 2-3 weeks wait. $20 per session.

Couples/family session: Online or phone with an intern. 6-8 weeks wait. $35 per session.

"Pay what you can" (up to 4 free) session for unemployed individual: Online or phone with an intern. 6-8 weeks wait.

Note: this service is only available Mondays to Fridays, between 9 am to 5 pm

I want to work with a private therapist and will choose one of the options below - or am I not interested in counselling so will be choosing 1-2 coaching options instead

NOTE: if you chose an option above please skip this section. Select any of the following if an appointment with a Private Clinical Counsellor or Private Registered Therapist best suits your needs Please only choose one counselling option (with intern or with a private registered therapist). Please only select one of the options: services with intern, or services with registered therapists

I chose one of the options above - or am not interested in counselling so will choose 1-2 coaching options instead

Low income earner requesting individual session with a Private Clinical Counsellor: Online or phone. 1-2 days wait. $50 per session.

Low income earner requesting couples/family session with a Private Clinical Counsellor: Online or phone. 1 week wait. $75 per session.

Individual with coverage OR high income: In-person (Surrey, BC) or online with a Private Registered Therapist. Minimal waits (1 week). $110-$140 per session.

Couples/family with coverage OR high income: In-person or online with a Private Registered Therapist. Minimal waits (1 week). $150-$225 per session.

Integrative Somatic Therapy Practice (ISTP) Trauma Counselling: Online or phone with a Clinical Counsellor. 1-week wait. $95/session (85 minute session)

Select any of the following if a free coaching service best suits your needs (whether on its own, or in addition to counselling). Please note: This is coaching/education, not therapy. These are one-to-one sessions, faciliated by interns. These programs are facilitated in English only. Please choose only 1-2 of the options below - once you complete those you are welcome to access additional coaching programs. 2-4 weeks wait.

Individual Life Skills coaching: Online with an intern or volunteer. Minimal wait. Free 12-session series. In English only

Healthy relationships coaching: Online with an intern or volunteer. Minimal wait. Free 10-session series. In English only

Mindfulness coaching: Online with an intern or volunteer. Minimal wait. Free 6-session series. In English only

Parent Coaching. Online with an intern or volunteer. Minimal wait. Free 10-session series. In English only

Seniors support (ages 55+). Weekly phone call with an intern or volunteer consisting of a check-in and a facilitated self-care activity. 5-20 minutes per call. Minimal wait. Free. In English only

Select any of the following if interested in a group session. Topics include stress, anger, mental health, substance use, healthy relationships, and self-care. Note group dates/times are set once there is enough interest to proceed

Women's life skills group: English

Men's life skills group: English

Youth (ages 12-17) Mental Health Group: English

Women's life skills group: Punjabi & Hindi

Women's life skills group: Farsi

Men's life skills group: Punjabi & Hindi

Women's life skills group: Arabic

Women's life skills group: Mandarin

International Students Support Group

How did you hear about Moving Forward Family Services?

Were you referred by someone?

Yes No

Please provide the name of the person or agency who referred you.

Phone number of referring agency.

Email of referring agency.

By submitting form, I acknowledge the following:

I acknowledge that certain services may only be available to me if I am a low income earner. I understand I may be required to provide proof of low income. If choosing to see an intern, I acknowledge that I have not been able to access services through the agencies responsible for publicly funded counselling. I understand that these services have a maximum number of sessions.

I understand that if I am choosing a service with an intern, they may have limited prior experience and cannot offer specialized services, such as psychological assessment. They also will not provide detailed letters for court/probation/social worker.

Once an appointment is made, I will make every effort to attend. I will provide a minimum of 24-hours advance notice if I cannot attend. I understand that missed appointment fees may be charged and/or services will be discontinued if I miss multiple appointments.

I understand that while services are offered across Canada, MFFS is based in British Columbia, Canada, and follows provincial laws related to service agencies.

Further Information and Disclaimers

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