Referral Source: Self-referred Family Physician/Other Mental Health Clinicians
Name: Required Relationship to client:
Client Information: Parent name(s) if minor (under age 18):
Gender: Male Female Trans Nonbinary
Ok to leave a message? Yes No
Email: Required
Appointment Availability: Required Mon Tue Wed Thu Fri Sat Morning Afternoon Evening
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 Tuesdays 4:30 - 6:30pm Wednesdays 5:30 - 7:30pm Thursdays 4:30 - 6:30pm Not Applicable
Adolescent Skills Group Availability: Required Wednesdays 4:30 - 6:00pm Wednesdays 5:30 - 7:00pm Not Applicable
Insurance Information: Yes No Unsure
Is the client willing to see a master- or doctoral-level graduate student in a doctoral psychology program (supervised by a Registered Psychologist) for a reduced fee?Yes No Unsure
What type of service are you interested in seeking? Individual therapy (any) Individual cognitive behavioural therapy Individual DBT-informed therapy DBT adolescent skills group DBT adult skills group Both individual therapy and skills group therapy (comprehensive DBT) Couples or Family Therapy Unsure
How would you like this service to be delivered? In Person Online No preference
If you are interested in attending one of our skills groups only, are you currently seeing a clinician for individual therapy? Yes No
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? Male Female No 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)Yes No
Anger problems? Yes No
Perfectionism? Yes No
Stress and anxiety about work or academic performance? Yes No
Interpersonal conflicts? Yes No
Parenting difficulties? (Please specify age and gender of your child under "Other reasons or concerns for seeking treatment" below)Yes No
Symptoms of depression? (e.g., low mood, loss of interests or motivation, concentration difficulty, feeling guilt, irritability)Yes No
Symptoms of anxiety (e.g., panic, tight chest, rumination, muscle tension, lots of worry thoughts, avoidance behavior)? Yes No
Self-harming behaviors in the past 6 months? Yes No
Self-harming behaviors in the past 2 months? Yes No
Suicidal thoughts? Yes No
Suicide attempts in the past 6 months? Yes No
Suicide attempts in the past 2 months? Yes No
Hospitalized in the past 6 months for mental health reasons?Yes No
Hospitalized in the past 2 months for mental health reasons?Yes No
History of trauma? Yes No
If yes to trauma history, please briefly describe nature of trauma (e.g., physical assault, childhood neglect, sexual assault, intimate partner violence):
Eating disorder concerns? Yes No
Alcohol or drug problems? Yes No
History of psychosis? Yes No
If yes to psychosis history, please briefly specify nature of psychosis (e.g., auditory hallucination, paranoia and delusional disorders) and whether symptoms are currently managed by medications:
Are you seeking mental health treatment because of any legal involvement (e.g., ordered by a judge, ICBC claim, custody battle)? Yes No
Other reasons or concerns for seeking treatment:
We appreciate your referral. Once we receive your referral form, we will try our best to connect you with one of our clinicians as soon as we can. Please note that due to overwhelming demand for services, there could be a wait time for clinicians depending on the type of service you are seeking and your availability for appointments. In general, the more flexible your schedule is for appointments, the sooner we would be able to offer you services. Wait time for online/virtual appointments is relatively short. Wait time for clinicians with DBT training is longer. Thank you for your patience and understanding.
