The Informed Consent for Minors – 12 Years and Under is for you as the parent and/or guardian to complete on behalf of your child. It is a legal document containing a contractual agreement between the client and the 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 counsellor will go over it with you. At this time, both you and your counsellor will sign the Informed Consent. You will retain a copy and your counsellor will retain a copy which will be placed in your file. Do not email this document since it requires your original signature and contains your personal information.

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 counsellor 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 Forms

Ivone Juell

MA, MA, RPC, MPCC-S

The Door of Hope Counselling Clinic would like to thank the person and/or agency that referred you to our Clinic. If applicable, we also would like to invoice the person and/or organization for the full rate or sliding scale rate for the counselling session(s) fees. Therefore, with your permission, could you please complete the Referral for Counselling form that is applicable to you and bring it into the Door of Hope Counselling Clinic. Thank you.

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The Informed Consent (Adult) is a legal document containing a contractual agreement between the client and the 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 counsellor will go over it with you. At this time, both you and your counsellor will sign the Informed Consent. You will retain a copy and your counsellor will retain a copy which will be placed in your file. Do not email this document since it requires your original signature and contains your personal information.

Client Personal Profile

This Informed Consent Adolescent is for you to describe yourself, your health, your family, your place in the world and any other relevant information. It is a legal document containing a contractual agreement between the client and the 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 counsellor will go over it with you. At this time, both you and your counsellor will sign the Informed Consent. You will retain a copy and your counsellor will retain a copy which will be placed in your file. Do not email this document since it requires your original signature and contains your personal information.

Informed Consent (Adolescent)

Payment Options

The purpose of this questionnaire is to get a complete picture of your couple, marital, and family background. In marriage and family therapy we are concerned with issues that impact on you, your marriage, and your family from many sources. Therefore, answering these routine questions as fully and as accurately as you can will make it possible for us to work on the things that concern you much more quickly.

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 in the office at the time of your first visit, if needed.


To open the downloadable PDF or MS Word document, please click on the file name.

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Contact

Office Hours


Monday to Friday - 9:00am to 5:00pm

(By Appointment Only)

Saturday - Closed

Sunday - Closed

Door of Hope Counselling Clinic

is ranked as a top
Counselling & Mental Health Service
in Port Coquitlam BC
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Call Us: 604-790-9032

Authorization for Live Observation &

Audio-Visual Recording

Ivana Redmond

RPC, MPCC

Olga Barrows
MA (In Progress)


Contractual Agreement

This contractual agreement is between the Door of Hope Counselling Clinic and Client concerning Client’s Insurance coverage for counselling services provided.

Authorization for Release of Information (Minor)

Application for Fee Reduction

Authorization for Release of Information (Adult)


Door of Hope Counselling Clinic
2606 Kingsway Ave.
Port Coquitlam BC V3C 1T6

Phone:604-790-9032
Email:info@doorofhopecounselling.com

Informed Consent (Adult)

Serving Greater Vancouver Since 2013

It is our desire to offer compassionate help when life becomes a struggle. We believe that no one should suffer alone. To make counselling more affordable for anyone who requires services but cannot afford a full fee, we adjust our fees based on your gross household income. There is a limit on availability to subsidize and reduce fees. Reduction of fees will periodically be reviewed. Please complete the Application for Fee Reduction and bring it into the Door of Hope Counselling Clinic.

Life History Questionnaire

Referral for Counselling

Informed Consent for Minors