Richmond

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's Name (Child / Service recipient): *

First

Last

Client's Date of Birth: *

Pronouns:

Parent's Name (The referring guardian completing this form): *

First

Last

Email: *

Secondary Email:

Is there another email that you would like correspondence sent to as well (e.g., another parent)?

Phone: *

Address: *

Address line, City, Province, Postal code

Name of School and Grade (if in school): *

Teacher Name and Email: *

Is this referral for your child? *

Please provide the names of all legal guardians (if client is under 19): *

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.

Marital status of parents/guardians: *

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

If separated or divorced, has sole guardianship has been established? (You will need to submit the supporting paperwork when contacted by our intake team) *

Yes, I have documentation of sole guardianship
No, I do not have documentation of sole guardianship
No, sole guardianship has not been established
Not applicable (parents are together/married)

Please note that ABLE Clinic is not able to provide psychological services if guardianship is in active dispute and all parties do not consent to services.

If sole guardianship has not been established, please provide an email address for the other parent/guardian to allow us to obtain their consent: *

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

Please note, we do not do direct billing for extended health benefits.

Would you be willing to see a supervised practitioner? *

Supervised practitioners often are available with shorter wait times and most bill a lower hourly rate than registered professionals which can reduce the cost of services. Supervised practitioners are not yet registered with the College of Psychologists of BC and are closely supervised by Registered Psychologists here at ABLE Clinic. You will not be charged for the cost of this supervision.

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

What is the primary language spoken in the home? *

Would you require a translator during the assessment? (If yes, you would need to arrange for a professional interpreter to be apart of the assessment) *

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 or intervention. *

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

Please list any previous assessments or diagnoses: *

Please put "N/A" or equivalent, if there is no relevant history for this item or the next.

Please list any current or historical mental health concerns as well as treatment received (i.e. self-injurious behaviours, ER visits, inpatient admissions, suicidality, outpatient treatment): *

Providing this information will help us assign the appropriate clinician to support/assess your child.

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

Surrey

Phone

* 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

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Intake Form - Richmond Clinic

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Intake Form - Richmond Clinic

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