New client intake form Name * First Name Last Name Email * Phone * (###) ### #### Preferred contact method? * Phone Call Email Text Message Type of Session * Please check your preferred first-session type. Face-to-Face (in office) Online Walk-and-Talk beside the Vedder River Demographic * The requested counselling is for: Child (5-12) Youth (13-18) Adult (19+) Couple Family Please share your reason for seeking counselling. If the client is a Child/Youth, what is their full name and date of birth? If there is another legal guardian/parent, what is their contact information? We will need to contact them to obtain consent to proceed. Please list the following below: Childs full legal name, age and date of birth followed by the legal guardian's full name, phone number and email address. If requesting Couples/Family counselling, we need to get in touch with all participants prior to booking. Please list full names, emails, and ages of each person who will be participating in the session. example: Person 1 - Name - Age - Email Address Preferred Appointment Days and Times * Please include as many options as possible below for when you are generally available week-to-week. Affiliation or Claim Information. * If relevant, please indicate which of the following fields apply. Please note, most extended health plans will cover counselling by a Registered Clinical Counsellor (RCC) - please verify your coverage with your plan provider. Please note, New Heights Counselling does not direct bill to extended health plans. You will be issued a detailed receipt which you can submit to your plan directly for quick reimbursement. I will be submitting receipts to my extended health plan I will be paying privately/out-of-pocket Crime Victim Assistance Program ICBC WorkBC BC Emergency Health Services How did you hear about New Heights Counselling or Kelly TeBrinke (required): Keep in Touch! I agree to be added to the New Heights email mailing list in order to receive important clinic updates to services, free mental health resources, and a monthly newsletter. Thank you!
