Client Interest Form

Looking Glass Counselling | Bridge the GapTM will offer accessible one-to-one therapeutic support to individuals who are struggling with an eating disorder. This program will be offered at an affordable $35 / hour. A small number of partial bursaries may be available.
 
Therapeutic support will be provided by practicum students enrolled in full-time studies at an accredited B.C. university, in a relevant discipline at the graduate level. Students will be overseen by a Registered Clinical Counsellor.
 
Please review the following criteria before completing this Client Interest Form:
  • Clients must be 19 years or older.
  • Clients must be struggling with disordered eating or a diagnosed or self-diagnosed eating disorder.
  • Clients must be recovery focused and willing to work closely with a therapist to help them meet their recovery goals.
  • Clients will be offered up to 10 months of support and must be willing to change therapists if necessary.
  • Clients must be willing to attend therapy sessions weekly or every two weeks, and be committed to attending their sessions as scheduled.
  • Co-morbidities are not a barrier; however, if the individual is reporting health impacts that require medical intervention, the program has the right to recommend/request the individual follow up with their general practitioner or other care provider to ensure physical safety and capacity to undertake therapeutic work.
  • Clients must not have had a suicide attempt in the past six months.
  • Clients cannot be in a hospital or residential treatment program at the time of seeking therapy through this program, however they can be on waitlist for hospital or residential care.
  • Clients must reside in B.C.
  • At the beginning and end of the counselling relationship, clients will be provided information on other eating disorder resources and will be encouraged to access additional support programs or services.
Please provide the following information, which will help us determine if we are able to support you through this program. It will also enable us to better understand the communities we support. Your personal information is confidential.
1.Name(Required.)
2.Email(Required.)
3.Cell Phone(Required.)
4.Date of Birth (dd-mm-yyyy)(Required.)
5.What is your current age?
6.Address(Required.)
7.City/Town(Required.)
8.Postal Code(Required.)
9.Languages
10.Gender Identity
11.Pronouns
12.Do you identify as a member of the 2SLGBTQ+ community?
13.Ethnicity (check all that apply; options are from Statistics Canada)
14.Have you experienced any of the following barriers to care in relation to your eating disorder? (check all that apply)
15.Have you had a suicide attempt in the past 6 months? (this isn’t necessarily a barrier to entry in the program but will help us get a fuller picture)(Required.)
16.Have you had a hospital admission related to your eating disorder or mental health in the past 6 months? (this isn’t necessarily a barrier to entry in the program but will help us get a fuller picture)(Required.)
17.How did you hear about Bridge the Gap?
Thank you for submitting your Client Interest Form. It will be reviewed and we will follow up with a phone call. Please note that counselling spots are very limited. We will let you know whether or not a counselling spot is available.