Parent/Guardian Name (if applicable)

First Name

Last Name

Client Name *

First Name

Last Name

Phone *

(###)

###

####

What services are you interested in? *

Therapy

Assessment

Do you have a referral *

A referral is not required to join the waitlist. However, if you have been referred, providing this information can help us better understand your needs.

Yes

No

Referred by (if applicable)

GP/Paediatrician

Psychologist/Counsellor

School/Teacher

Other

Consent *

I consent to being added to the clinic's waitlist and understand that placement on the waitlist does not guarantee an appointment. I agree to be contacted when an appointment becomes available

I consent

I do not consent