Child's Name * First Name Last Name Caregiver's Name First Name Last Name Caregiver's Email * Caregiver's Phone Number (###) ### #### Area of Residence Child's Age Services Requested * Early Childhood Services Elementary Age Services Adolescent Services Has Your Child Received a Formal Diagnosis? * Yes No Is Your Child Currently Seeing a Psychologist, Psychiatrist, Counsellor or Other Health Professionals? * Yes No Checklist for Behavioural Concerns * Which form of behavioural concern(s) does this apply to your child? Aggression & Oppositional Defiance Attention or Hyperactivity Issues (ADHD) Autism-related Challenges Executive Functioning & Planning Emotional Regulation Challenges School Refusal or Truancy Social Skills Challenges Other Concerns Primary Concerns or Specific Requests Do You Have Any Questions for Us? We’ve Received Your Form!We will contact you in less than 48 hours.Talk to you soon 😁 Pre-Consultation Intake Form
