Waitlist Survey

This form has been created to join the waitlist for counselling sessions with Paige Mathison (RCC Designation in Process). The projected start date is April or May of 2022 pending counselling registration.

**If you need urgent mental health care, reach out to a counselling program accepting clients at this moment. If you need emergent care, especially regarding safety concerns (harm to self or others), contact a crisis line or go to your nearest emergency department.

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* 1. What is your full name?

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* 2. What are your pronouns? (Mine are She/Her)

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* 3. Before continuing, what are your hopes from this form?

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* 4. What format of counselling would you prefer?

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* 5. What is your phone number?

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* 6. What is your email address?

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* 7. How would you prefer to be reached?

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* 8. What city or town are you located? (Registration & liability insurance only cover clients residing in British Columbia)

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* 9. Do you have benefit/insurance coverage for a Registered Clinical Counsellor? (Cost per 50 minute session: $135.00)

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* 10. Important Information
1. Being added to the waitlist does not guarantee that you will become a client with Paige Mathison.
2. An intake process would still need to be completed to determine that the services fit your needs or are within the counsellor's abilities to provide support.
3. The waitlist will be reviewed once approval of counselling registration is granted. Do not anticipate a response until the practice's opening date has been determined.
4. You will not be added to a promotional email list by filling out this form. You will only be contacted regarding services opening.
5. You are in no way obligated to be client with Paige and are welcome to decline when contacted.

Please read all of the points noted in Question 10 and type your full name below to show you understand the information provided.