Referral Form For Professionals

Client Information

Client First Name *

Client Last Name *

Is the client 19 years or older?YesNo

Phone

Preferred contact method

Parent / Guardian First Name

Parent / Guardian Last Name

Parent / Guardian Email

Parent / Guardian Phone

Preferred contact method for parent / guardian

Type of Service

Preferred Counselling Format

Counsellor Preference

Will the client be located in BC for the duration of counselling?Most of our therapists are able to work only with residents of British Columbia, though temporary travel outside of BC during counselling may still be possible.YesNo

Which province/country will you be in?

Does the client have extended coverage or a third-party funding source?We can provide receipts for reimbursement through the client's insurance or coverage plan, and in some cases may invoice third-party funders directly. We will confirm billing arrangements with the client prior to their first session.Autism Funding BC (AFU)Crime Victim Assistance Program BC (CVAP)First Nations Health Authority (FNHA)Insurance Corporation of BC (ICBC)Other

Reason for EMDR Therapy0 / 4000

Referral Source Information

Referral Source First Name

Referral Source Last Name

Referral Source Email

Referral Source Phone

Agency/ Organization Name

Would you like us to contact you once we have reached out to the client / parent / guardian?YesNo

How did you hear about us?

We respect your privacy and handle all information in accordance with Canadian privacy law, including Personal Information Protection and Electronic Documents Act (PIPEDA).