client Forms

The following documents must be printed, reviewed and signed before your first visit. Doing this in advance will save valuable time and frustration and will allow us to immediately get underway with your initial visit. Please review carefully and have ready any questions you might have. Forms will also be available at the time of your first visit, if needed. To open the downloadable PDF document, please click on "Download". 

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Client Personal Profile

The Client Personal Profile is a questionnaire that contains various questions relating to you, your family, and your life experiences. Please read, complete the questionnaire, and bring the Client Personal Profile with you to your first session and your Therapist will go over it with you. We recommend for you to not email this document since it contains your personal information and any Internet-based communication is not guaranteed to be secure / confidential. However, if you choose to send your completed Client Personal Profile via the internet, we cannot take responsibility for any risks involved. If this is your personal choice, then you can email it to: info@doorofhopecounselling.com

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Client Personal Profile – Ivone Juell (pdf)

Download

Client Personal Profile – Ivana Redmond (pdf)

Download

Informed Consent (adult)

The Informed Consent (Adult) is a legal document containing a contractual agreement between the client and the Therapist / Clinical Counsellor. It describes the rights and responsibilities between both parties. Please read and bring the Informed Consent with you to your first session and your Therapist / Clinical Counsellor will go over it with you. At this time, both you and your Therapist will sign the Informed Consent. You will retain a copy and your Therapist will retain a copy which will be placed in your confidential file. Do not email this document since it requires your original signature and contains your personal information.

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Informed Consent (Adult) – Ivone Juell (pdf)

Download

Informed Consent (Adult) – Ivana Redmond (pdf)

Download

informed consent (minor / adolescent)

The Informed Consent Minor / Adolescent is a legal document containing a contractual agreement between you, your child, and the Therapist. It describes the rights and responsibilities between all parties. Please read and bring the Informed Consent (Minor / Adolescent) with you to your first session and the Therapist will go over the Informed Consent with you. At a later time, the Therapist will also go over the Informed Consent with your adolescent child. The Informed Consent will be signed by all parties--Parents / Legal Guardian(s) / Adolescent (13-18 years of age), and Therapist. You will retain a copy of the signed Informed Consent and the Therapist will retain a copy which will be placed in your child's confidential file. Your child, 12 years of age and under, is not required to sign the Informed Consent. 

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Informed Consent (Minor & Adolescent) – Ivone Juell (pdf)

Download

Informed Consent (Minor & Adolescent) – Ivana Redmond (pdf)

Download

Authorization for release of Information (adult)

Authorization for Release of Information (Adult) - Ivone Juell (pdf)

Download

Authorization for Release of Information (Adult) – Ivana Redmond (pdf)

Download

authorization for release of information (minor & adolescent

Authorization for Release of Information (Minor & Adolescent) – Ivone Juell (pdf)

Download

Authorization for Release of Information (Minor Child) – Ivana Redmond (pdf)

Download

Credit card authorization form

To make a payment via Credit Card (Visa, Mastercard, or American Express) please click on "Download". Complete the form, sign, and bring to your session. If you choose, you can also email it to the Director of Operations at info@doorofhopecounselling.com. Please let us know if you authorize the Door of Hope Counselling Clinic in Port Coquitlam to keep your Credit Card information on file to process your payment for future sessions.

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Credit Card Authorization Form (pdf)

Download

authorization for live observation & audio-visual recording

Authorization for Live Observation and Audio Video Recording (pdf)

Download

competency-based clinical counselling letter

This detailed letter explains the extensive qualifications of a Registered Professional Counsellor (RPC) and / or Master Practitioner in Clinical Counselling (MPCC) who is registered with the Canadian Professional Counsellors Association (CPCA).

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Competency-Based Clinical Counselling Letter - CPCA (pdf)

Download

Contact Form

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Door of Hope Counselling Clinic, Inc.

A113 – 2099 Lougheed Hwy. Port Coquitlam, BC V3B 1A8

Call Us: (604) 790-9032

Clinic Hours

Monday - Friday: 

9:00am - 6:00pm 

(By Appointment Only) 

Closed Saturday & Sunday