Counselling Service Request Form

Note: if you are referring a client (whether as a referring agency, or if you are family member): to ensure our long-term sustainability, we request that you explore the possibility of covering the fees if the client cannot afford to pay.

COUNSELLING SERVICE OPTIONS - Please choose either services with Intern (Student on a practicum) OR Registered Therapist. Sessions are 50 minutes.

Health Authorities, Education, Corrections, Post-Secondary Education, 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 - and only to clients who are unemployed. If you work, you would be expected to pay for services. Note that missed sessions without advance notice may incur fees / count towards free sessions, and 2 missed sessions may result in discontinuation of services.

While we do our best to address the massive gaps in services around mental health care, we may not be the best fit for your needs - especially since our interns and registered therapists offering the lowest fee services are newer practitioners. In such cases, we encourage you to look for other options in the community.

In-person services have minimum fees attached (as there are considerably higher costs associated with in-person services such as space, maintenance and fuel to and from office).

Once a counsellor is assigned, they will call you and if possible, leave a message, as well as attempt to contact you through email; they will wait one week for a reply and then move onto other clients on the wait list - this practice ensures we are following up with counselling service requests as quickly as possible.

Please note that for any services provided by interns: our interns will not provide reports, assessments, or diagnoses. If your case involves pending/recent family/criminal court, employment, litigation, ICBC, and complex matters consider requesting more experienced registered therapists.

Moving Forward Family Services will deny services to anyone who expresses views that contradict human rights as outlined in the BC and Canadian Human Rights Code.

Section 1 - Choose one of these options if you are low income/have no income, and have no insurance coverage. Choosing multiple options will slow down the time it takes to assign the therapist

Section 2 - Choose one of these options if you are a low income earner but want to work with a private registered therapist who offers reduced fee services for low income clients. Note: proof of low income may be required by the therapist. This service under these fees is not eligible for insurance. To prevent someone from using insurance at these rates, any receipts requested will not have information required for insurance reimbursement - such as registration number of the therapist, their address, etc.

Section 3 - Choose one of these options if you are a high income earner, have insurance, or have funding through ICBC or Crime Victim Assistance Program. Choosing multiple options will slow down the time it takes to assign the therapist. Therapist may initially reach out by email so please keep an eye out (and also check your spam/junk folder)

PLEASE stop and review your selections above - to ensure you only selected ONE option.

Choosing multiple options will delay response times (as it requires us to follow up to clarify which the options). Also please ensure you have read each option (and its associated wait times carefully).

Section 4

ADDITIONAL SERVICES:

Coaching and Group Programs:

We offer numerous additional services to support our communities' well-being. We suggest wherever possible to engage in therapy as well as accessing psycho-educational coaching support and attending group.

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 (will be reviewed at 12 sessions) and would be reviewed by supervisor to determine if any extensions are provided

I am aware there are waits based on service I chose - and that the therapist will attempt to call me as well as email me, and that if I do not follow up within one week that the file may be closed

I understand that while Moving Forward Family Services is a low barrier service, it may not address all of my needs, and thus will continue to explore other options (public sector and/or private)

When a client is at risk for or has attempted suicide, and a Moving Forward Family Services Society staff member becomes aware of this, the staff member will do the following:

1) Promptly disclose this information to their Clinical Supervisor, Manager and the Executive Director

2) Provide an assessment of the situation

3) Determine the risk of danger to others: this encompasses family members, acquaintances, and the client

4) In the circumstance in which the client is a minor the staff member will initiate contact with the minor’s parent or guardian and appropriate ministries if applicable.

5) In the occurrence of an attempt of suicide, a contact to the local authority will be made and appraisal of the situation will be disseminated to the authority

6) If required call an ambulance or contact an appropriate agency for crisis intervention

7) Ensure highest measure of confidentiality by only initiating contact with other agencies on a need to know basis such as school officials, counselors, mental health professionals, or family physician.

8) In collaboration with all involved professions institute a follow up procedure to ensure a level of communication exists among all personnel

9) Supervisor is notified as soon as possible

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. A basic letter outlining number of sessions and generally what was discussed in sessions can be provided free of charge - such a letter must be requested a minimum of four weeks before it is required. Any request made with a shorter deadline will be subject to an administration fee of $50. While a basic letter can be provided free of charge, a request for the complete client file will be charged a minimum administration fee of $75.

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 (two or more) appointments. If a service is discontinued due to missing multiple sessions, an administration fee to reactivate file of $20 will be administered.

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

I understand that services are fee-based, with limited free services reserved for those who do not work

I understand that Moving Forward Family Services reserve the right to refuse service to anyone who engages in aggressive behaviour (yelling, profanity) derogatory language towards the therapist/social worker, or anyone who consistently books appointments and then does not show.

I understand Moving Forward Family Services will deny services to anyone who expresses views that contradict human rights as outlined in the BC and Canadian Human Rights Code

I understand that Moving Forward Family Services reserve the right to refuse services to anyone who makes demands for services we cannot provide and continues to make such demands (i.e. someone wanting an experienced therapist with specializations, but only wanting a free service).

That if I have not heard back after the approximate wait time, I can email gary@movingforward.help to check on status of my file