Richmond

Richmond Clinic location:

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

Phone Number
+ 604 - 207 - 1984

Fax Number
+ 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.

Client Name *

First

Last

Date of Birth *

Sex *

School

ALL Legal Guardian Names (If client is under 18) *

Marital Status of Parents *

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 no, do you have documentation of sole guardianship?

Best Phone Number *

Email *

Address *

Address line, City, Province, Postal code

Is this referral for your child? *

Are you planning on submitting your receipts to 3rd party insurance? *

Yes
No
Coverage doesn't matter

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

What are your child's verbal abilities? *

None
Some Words
Short Sentences
Fluent/Age Appropriate

What are your goals for the assessment or intervention? *

What previous assessments or diagnoses has your child received? What professionals have you seen regarding your concerns, if any? *

Service(s) requested *

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

Name

* 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

ABLE Developmental Clinic Inc.

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