Forms &
Referrals
Welcome to Your Counselling’s Forms & Referrals Centre. This page provides quick access to the forms needed for different services and situations. To make things simple, the table below explains when each form is used. Please choose the one that best matches your needs.
If you’re unsure which form is right for you, our Client Services Team is happy to help. You can reach us at reception@yourcounselling.ca or by phone during regular office hours.
Third Party Payment
To be signed by the client (18 years and older) if another party is paying for their sessions.
STCF Statement of Understanding
To be completed in addition to an intake form if the client is attending the Start the Conversation Counselling (Sliding Scale Program in Acuity).
ESS Statement of Understanding
To be completed in addition to an intake form if the client is attending counselling sessions with an ESS Agreement.
Single Session Intake & Consent
To be completed by an individual 18 years and older who is attending Single Session counselling.
Offsite Consent & Agreement
To be completed in addition to an intake form if the client is attending counselling sessions outdoors. (ie. Walking in park)
Walk In Intake & Consent
To be completed by an individual 18 years and older who is attending Walk-In counselling.
Child Counselling Intake & Consent
To be completed by the legal guardian(s) of an individual 17 years and under who is attending a counselling session.
Adult Guardianship Intake & Consent
To be completed by the legal guardian of an individual 18 years and older who is attending a counselling session.
Group Therapy Intake & Consent
To be completed by the individual attending a group therapy session.
Adult Intake & Consent
To be completed by an individual 18 years and older who is attending a counselling session.
Insurance Authorization
Complete this form to set up direct billing through an insurance provider
Adult Referral
For healthcare providers and community organizations to refer clients to Your Counselling Ltd.