Your Counselling Ltd.

Forms & Referrals

Quick access to every form for our services and programs. Pick the one that matches your situation.

Welcome to Your Counselling’s Forms & Referrals Centre. Each form below explains when it’s used, so you can quickly find the one that matches your situation and get started.

Not sure which form to use? Reach our Client Services Team at reception@yourcounselling.ca or by phone during regular office hours.

Intake & Consent

Start with the intake that matches your situation. You only need the one.

Adult Intake & Consent

To be completed by an individual 18 years and older who is attending a counselling session.

18+ · IndividualOpen form

Single Session Intake & Consent

To be completed by an individual 18 years and older who is attending Single Session counselling.

18+ · Single SessionOpen form

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.

Guardian · Under 18Open form

Adult Guardianship Intake & Consent

To be completed by the legal guardian of an individual 18 years and older who is attending a counselling session.

Guardian · AdultOpen form

Group Therapy Intake & Consent

To be completed by the individual attending a group therapy session.

Group therapyOpen form

Psychosocial Intake & Consent

The Psychosocial Intake Form is designed to gather comprehensive information about your psychological, social, and emotional well-being.

Detailed intakeOpen form

Additional Agreements

Some programs and situations need a short agreement completed alongside your intake.

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).

Program add-onOpen form

ESS Statement of Understanding

To be completed in addition to an intake form if the client is attending counselling sessions with an ESS Agreement.

Program add-onOpen form

Offsite Consent & Agreement

To be completed in addition to an intake form if the client is attending counselling sessions outdoors. (ie. Walking in park)

Session add-onOpen form

Third Party Payment

To be signed by the client (18 years and older) if another party is paying for their sessions.

18+ · Billing add-onOpen form

Billing & Referrals

Set up direct billing, or refer a client to our team.

Insurance Authorization

Complete this form to set up direct billing through an insurance provider

Direct billingOpen form

Adult Referral

For healthcare providers and community organizations to refer clients to Your Counselling Ltd.

For providersOpen form