Richmond

Please complete the following intake form to initiate a referral and/or to join our waitlist. Upon receipt, one of our clinic coordinators will contact you to discuss next steps. Please make sure to check your email (including your junk folder) when waiting for a response. Please allow 2-3 business days to get a response. Please note that there is a waitlist for all assessments and availability is limited at this time in our Richmond location.

We apologize for the inconvenience, but our waitlist for adult ASD assessments is currently closed.

Client's Name (Child/Service recipient): *

First

Middle

Last

Date of Birth - dd/mmm/yyyy (e.g. 05/APR/2018) *

Sex *

Pronouns: *

Name of individual completing intake form *

If other, please describe:

Email: *

Secondary Email:

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

Phone: *

Secondary Phone:

(e.g. second parent's email)

Address: *

Address line, City, Province, Postal code

If the client is under 19, please provide the names of ALL legal guardians:

e.g. Someone who is appointed by the court who has the authority to make health care decisions on behalf of the child

Martial status of parents/guardians:

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

Yes
No
Not applicable, I am an adult client

We are required to have consent from all legal guardians in order to provide services for children. If this is a concern, please let us know as soon as possible.

If separated or divorced, has sole guardianship 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)
No, both guardians have shared guardianship rights
Other

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.

Name of School and Grade (if in school/homeschooled):

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 is the primary language spoken in the home? *

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

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. *

e.g. challenging or concerning behaviour

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

e.g. teacher's concern, pediatrician suggestion, and their concerns

Please list any previous assessments and/or diagnoses:

(e.g. Developmental Pediatrics, Speech-Language Pathology, Psychiatry/other Mental Health, Hearing/Audiology, Occupational Therapy, Physical Therapy, Behaviour Therapy/ABA, Education, Psychologist/Counselling etc.

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 you

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

Surrey (their waitlist is open for psyched assessments only)

*If your requested service is for psychoeducational assessment only, there is a waitlist open in Surrey with a similar wait time. Please check the box if you are interested in having your intake shared.

Phone

Thank you for completing the intake form. Please make sure to check your email (including your junk folder) for a confirmation that we received your intake. Please allow 2-3 business days. To proceed with services, please reply back to that email to confirm you agree with the next steps as discussed.

* 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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