Richmond

Richmond Clinic location:

Clinic Address
Pacific Family Autism Network
3688 Cessna Drive
Richmond, BC, V7B 1C7

Phone Number
1.604.207.1984

Fax Number
1.604.238.9222

Email Address
richmond@ableclinic.ca

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. Please note that there is a waitlist for all assessments and availability is limited at this time in our Richmond location

Client Name *

First

Last

Client's Date of Birth *

Pronouns

Email *

Phone *

Address *

Address line, City, Province, Postal code

Grade (if in school)

Teacher Name and Email *

Is this referral for your child? *

All legal guardian names (if client is under 18) *

Marital status of guardians *

Required by the College of Psychologists of BC, the BC association of Clinical Counsellors, and the BC Speech Language Pathology Association.

Are all legal guardians consenting to and/or participating in this assessment/treatment? *

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.

If sole guardianship has been established, are you able to provide proof?

Yes, I have documentation of sole guardianship
No, I do not have documentation of sole guardianship
No, sole guardianship has not been established

Please note that ABLE Clinic is not equipped to provide psychological services if guardianship is in active dispute.

Are you planning on submitting your receipts to third party insurance? *

Would you be willing to see a supervised practitioner? *

This shortens the wait time and lowers the cost - supervised practitioners are those who have not yet registered with the college of psychologists, but are closely supervised by registered psychologists here at the ABLE clinic.

What behaviours have presented as challenging or concerning to you? Please provide examples if possible. *

What is the primary language spoken in the home? *

What are your child's verbal abilities? *

None
Some words
Short sentences
Fluent/age-appropriate

What are your goals for the assessment or intervention? *

Reason for Request: Please give details, symptoms, etc, that you are seeing that make you feel there is a need for the assessment. *

History leading up to this request: when were you first concerned and by what? *

Please list any previous assessments or diagnoses:

Service(s) requested *

Autism Assessment
Psychoeducational Assessment
Counselling
Speech-Language Assessment
Speech-Language Therapy
FASD and/or CDBC Assessment
CLBC Assessment
Groups
Other (Specify above)

Would you like us to send your intake to our other locations as well? You can join multiple waitlists if you'd like.

Surrey

* 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.

Richmond

Richmond Clinic location:

Intake Form - Richmond Clinic

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Richmond

Richmond Clinic location:

Intake Form - Richmond Clinic

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ABLE Developmental Clinic Inc.

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