Secure Intake Form

If you are interested in seeking our services, please take a few minutes to fill out the secure online form (below). The directors will then review your information in order to establish a good match between you and your therapist. If you are only looking for our contact information then please go to the contact page.

To facilitate this process please fill out and submit the following form.

Please note: If you are not comfortable submitting your information online, please feel free to call us at 604-677-3286.

* = required entry

 


Demographic Information

* Name:
Name of Additional Client:
(if applicable)
Name of Additional Client:
(if applicable)
Age (if a child):
Name of Additional Client:
(if applicable)
Age (if a child):
 
* Has your partner/husband/wife expressed an interest in coming in with you? yes no
In the case of minor children, are other guardians aware of the request for services? yes no
 
Contact Information:

Please provide phone number where we may reach you & leave confidential messages.
* Home #:
Work #:
Cell #:
* Email:
* Full Address:
* Who referred you to our Centre?
If it is another professional, please indicate:
Doctor: Therapist: Other:


Clinical Information

* Services Requested (Check as many as apply):

Individual Therapy Couples Therapy Family Therapy Play Therapy Assessment
* Briefly describe some of the concerns you are seeking help for:
* Are there any concerns you have around physical safety or how you may be feeling
that you think your therapist should know about? yes no
If Yes, please describe your concern:


Preferences

* In matching you with a therapist, do you have any preferences you would like us to consider?
* What are your preferred appointment times?
We will do our best to accommodate you whenever possible. The more flexible you can
be, the sooner a therapist will likely see you.
* Do you have extended health coverage for the services? yes no
If yes, what is the name of the insurance company?  
We recommend that you check eligibility and coverage amounts with your extended health care provider.

* Do you want to receive information via email about upcoming VCFI Events or Programs? yes no
If yes, our office will contact you with more information.



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