Secure Intake Form

Should you want to proceed and seek our services, please take a few minutes to fill out the secure online intake form below. The directors will then review your information to determine which therapist will be a good match for you but in order to facilitate this process, we must receive a intake form. If you are not comfortable submitting your information online, you are welcome to call our office at 604-677-3286 during business hours and we can complete the intake form with you over the phone. All online intake forms submitted or received after 5:00pm on Friday and over the weekend will be responded to on Monday; Tuesday if Monday is a statutory holiday.

If you are only looking for our contact information then please go to the contact page.

* = 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
Hold Me Tight® Couples' Workshop (for more information, click here)
* 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

Regrettably, we are unable to accommodate any week day appointments after 4pm or weekend appointments at the present time and for the foreseeable future.

* In matching you with a therapist, do you have any preferences you would like us to consider?
* What are your preferred appointment times?
(e.g., Mon & Wed 1-4pm)
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?  
Please indicate the types of therapists covered by your insurance company:
(e.g. Registered Clinical Counsellor, Registered Marriage and Family Therapist, Registered Psychologist)
Alternatively, if you do not need to use your coverage if it helps you to receive services sooner, place a check mark in the space below.
I do not need to use my coverage if it helps me see a therapist sooner or gives me a wider choice of available therapists.
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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