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.

Client Name *

First

Last

Date of Birth *

Pronouns

Email *

Phone *

Address *

Address line, City, Province, Postal code

Grade (if in school)

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 practitioner without coverage if it shortened the wait time?

Yes
No, I need to use coverage

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:

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

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Intake Form - Richmond Clinic

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Richmond Clinic location:

Intake Form - Richmond Clinic

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ABLE Developmental Clinic Inc.

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