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Welcome To Our Client Forms Page

 The Online Intake Form & Informed Consent must be read, completed and signed Online before your first visit. This will allow the Therapist to immediately get underway with the Initial Assessment. 

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DESCRIPTION:

Intake Form

 The Intake Forms is a questionnaire that contains various questions relating to you, your family, and your life experiences. This document must be completed Online before your first session.  

Informed Consent (Adult)

 The Informed Consent (Adult) is a legal document, which describes the client and the therapist's role, rights and responsibilities related to their professional and therapeutic relationship. It must be signed by a client 19 years of age and over.   

Informed Consent (Minor / Adolescent)

The Informed Consent (Minor / Adolescent) must be signed by all parties--Parents / Legal Guardian(s) / Adolescent (13-18 years of age), and Therapist. Your child, 12 years of age and under, is not required to sign the Informed Consent.  

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Online Intake Form & Informed Consent (Adult)

 Please click on the Online Intake Form link below to be directed to this form on our Online Booking Site.  

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Online Intake Form & Informed Consent (Minor & Adolescent)

 Please click on the Online Intake Form link below to be directed to this form on our Online Booking Site.  

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Authorization For Release of Information Form

Please click on the download button below to download the Authorization for Release of Information Form. Then complete, sign, date, and send it to: info@doorofhopecounselling.com 

Authorization for Release of Information (pdf)

Download
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Competency-Based Clinical Counselling Letter - CPCA

This detailed letter explains the extensive qualifications of a Registered Professional Counsellor (RPC) and / or Master Practitioner in Clinical Counselling-Supervisor (MPCC-S) who is registered with the Canadian Professional Counsellors Association (CPCA). This letter could be sent to your Healthcare Provider if they cover a Registered Clinical Counsellor (RCC) but have rejected the claim that you have submitted for reimbursement from a Master Practitioner in Clinical Counselling-Supervisor (MPCC-S) or a Registered Professional Counsellor (RPC). 

Competency-Based Clinical Counselling Letter - CPCA (pdf)

Download

Contact Form

Door of Hope Counselling Clinic, Inc.

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

Call Us: (604) 790-9032

Clinic Hours

By Appointment Only


Monday - Friday: 9:00am - 7:00pm 

Saturday: Closed

Sunday: Closed