Counselling Application Form

Counselling Application Form

Phone and WhatsApp: (852) 9012 0086 (Hong Kong) (604) 727-1165 (Canada) Website: www.pcpt.ca Facebook: PCPT IG: pcpt_playtherapy.counselling Address: Unit 200-202, 8351 Alexandra Road, Richmond, BC, V6X 3P3
Personal Information
Name*

First NameLast Name
Phone Number*
Home/Work Phone
Email*
example@example.com
Residence Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Availability
Please select your availability for the given days and time phases*

Monday - DaysMonday - NightsTuesday - DaysTuesday - NightsWednesday - DaysWednesday - NightsThursday - DaysThursday - NightsFriday - DaysFriday - NightsSaturday - DaysSunday - Days
Who suggested this visit?*

MyselfFriendFamily MemberSchoolPhysicansOther
Have you been or are you presently seeing a person or agency which provides psychological or counselling services?

YesNo
Major concerns for seeking counselling: *
Client's Rights
1. The client may ask questions on what to expect during and end result of the therapy.

2. The client may decline to proceed with the therapy as to the techniques which may be conducted by the therapist.

3. The therapist has the right to dismiss the client from the course of therapy.

4. Right to confidentiality: Within limits provided for by law, all records and information acquired by the therapist shall be kept strictly confidential in accordance with the principles of a doctor-patient relationship. All information will not be shared or revealed to any person, agency, or organization without the client's prior written consent.

5. The client can raise any concerns and speak with the therapist immediately, provided that the therapist is likewise available to discuss matters with the client.
Acknowledgment of Consent for Counseling Treatment
I have reviewed this Professional Counseling Informed Consent Agreement. I likewise understand my Client's Rights set in this form.

I accept this agreement and consent to counseling.
Date

MonthDayYear
Date
Signature
Should be Empty:

Counselling Application Form

Personal Information

Availability

Client's Rights

Acknowledgment of Consent for Counseling Treatment