Self-referredFamilyPhysician/Other Mental Health Clinicians
Appointment Availability: Required
( Check all that apply; The more limited your availability, i.e., after school or work, the longer the wait may be to offer you service. )
If you are only available in the afternoon or evening for an appointment, what is the earliest appointment time you could make?
Adult Skills Group Availability: Required ( If applicable; Check all that apply )
Adolescent Skills Group Availability: Required ( If applicable; Check all that apply )
Does the client have extended health benefits coverage?
Is the client willing to see a master-level graduate student in a doctoral psychology program for a reduced fee?
What type of service are you interested in seeking? Individual therapyGroup therapyBoth individual and group therapy (comprehensive DBT)Couples or Family TherapyUnsure
How would you like this service to be delivered? In PersonOnlineNo preference
If you are interested in attending one of our skills groups only, are you currently seeing a clinician for individual therapy? YesNo
Please specific the type of clinicians you are currently working with (e.g., psychiatrist, counselor, social worker, psychologist) and the frequency of your meeting (if applicable):
Do you have preference for a male or female clinician? MaleFemaleNo preference. I will see whoever is accepting new clients so I can book an appointment sooner.
Reasons or Concerns for Seeking Treatment
Symptoms of obsessive compulsive disorder (e.g., obsessive thoughts, mental or physical repetitive, compulsive behavior)YesNo
Anger problems? YesNo
Stress and anxiety about work or academic performance? YesNo
Interpersonal conflicts? YesNo
Parenting difficulties? (Please specify age and gender of your child under "Other reasons or concerns for seeking treatment" below)YesNo
Symptoms of depression? (e.g., low mood, loss of interests or motivation, concentration difficulty, feeling guilt, irritability)YesNo
Symptoms of anxiety (e.g., panic, tight chest, rumination, muscle tension, lots of worry thoughts, avoidance behavior)? YesNo
Self-harming behaviors? YesNo
Suicidal thoughts? YesNo
Suicide attempts in the past six months? YesNo
Hospitalized in the past year for mental health reasons?YesNo
History of trauma? YesNo
Eating disorder concerns? YesNo
Alcohol or drug problems? YesNo
Are you seeking mental health treatment because of any legal involvement (e.g., ordered by a judge, ICBC claim, custody battle)? YesNo
Other reasons or concerns for seeking treatment:
We appreciate your referral. Due to overwhelming demand for comprehensive DBT, we currently have a wait time of at least 6 months for DBT service depending on the type of DBT clinician you are seeking (e.g., trainee vs. psychologist). Not all of our clinicians see clients in the comprehensive DBT program. Once we receive your referral form, we will automatically place you on our DBT waitlist and contact you when an opening might become available.
For inquiry of non-DBT services (e.g., individual CBT sessions, couples therapy, solution focused therapy etc.), we will try our best to connect you with a clinician within a couple of weeks. In general, the more flexible your schedule is for appointments, the sooner we would be able to offer you service.