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)

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

West Vancouver
Surrey
Just Richmond, please

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

Richmond Clinic location:

Intake Form - Richmond Clinic

ABLE Developmental Clinic Inc.

West Vancouver Clinic:

Surrey Clinic:

Richmond Clinic: