Surrey

Please complete the following intake form to initiate the referral process. Upon receipt, our intake team will contact you within ten days. Please also check your email junk folder. If you have not heard back from our office within two weeks of the date of submission, please give us a call at 604-584-3450. There may be a wait for assessment or intervention services. Please note our Surrey office current estimated wait times: Psychoeducational assessment 7-8 months, 6+ years ASD assessment at least18 months, Under 6 years ASD assessment at least 18 months. Thank you for your patience and we look forward to supporting you.

Client Name (Child/Service recipient) *

First

Last

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 Number *

Full Address *

Address line, City, Province, Postal code

Name of School and Grade (if in school) *

Teacher Name and Contact Information:

In the event we need to ask a teacher to participate in the assessment, please provide us their name and contact information (preferably 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 Clinic Counsellors, and the College of Speech and Hearing Health Professionals of BC.

Marital status of parents/guardians - Other:

Required by the College of Psychologists of BC, the BC Association of Clinic Counsellors, and the College of Speech and Hearing Health Professionals of BC.

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 legal documentation that I am the sole guardian
No, I have no documentation that I am the sole guardian
No, sole guardianship has not been established
Not applicable (parents are together/married)

If sole guardianship has not been established then both parents are required to provide signed consent for services (eg. parents are separated or divorced). 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? *

Do you have any third party funding? (ex. school, Variety, Jordan's Principle, First Nations Health Authority etc.) *

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? *

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, inpationt admissions, suicidality, outpatient treatment): *

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

Would you like your intake form sent to either of our other locations? You can join multiple waitlists if you'd like.

Richmond
West Vancouver

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* Please note, we cannot guarantee the confidentiality of information transmitted through e-mail including this intake form. If you are not comfortable with this limitation, please contact our office and we will provide an alternate submission method.

Surrey

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Intake Form - Surrey Clinic

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