Richmond Clinic location:

Intake Form - Richmond Clinic


Please complete the following intake form to initiate a referral and/or to join our wait list. Upon receipt, one of our clinic coordinators will contact you to discuss next steps.

We are required to have consent from all legal guardians in order to provide services. If this is a concern, please let us know as soon as possible.
Address line, City, Province, Postal code

* Please note, we cannot guarantee the confidentiality of information transmitted through e-mail including the intake form.  Please be aware of this limitation when contacting us.