New Client Inquiry Form

New Client Inquiry Form

For general inquiries, intakes, matching, and waitlists
Please take a moment to complete this New Client Inquiry Form. Please only fill in as much as you feel comfortable.

We will be in touch as soon as we can to help you set up an appointment if a suitable service provider is available or provide waitlist or referral options including resources.

We are committed to ensuring everyone can access therapy. Please also let us know if there is any barrier to communicating or accessing our services at hello@cherishclinic.com

Caregiver/Guardian Name*

First NameLast Name
Caregiver Pronoun
Client Name*

First NameLast Name
What is the client's pronoun
How old is the minor?*
Contact email*
Phone Number*
This would only be used as the last option to contact for missing appointments and billing issues
What city does the client reside in?*

Information for the Developmental Screening
The developmental screening has five parts:

Step 1: Intake, consent, deposits.

This is the intake form. Once the intake, consent and deposit have been made. We will contact you to schedule the sessions. The sessions will be scheduled closely with each other and sometimes on the same day.
The deposit is $160 + GST and is not refundable.

Step 2: Questionnaires

While you wait for the appointment, we will send you some questionnaires to complete. There are both parent and child questionnaires. However, please do not pressure the child to fill them.

Step 3: Parent session (60-90 minutes)

This would be a parent-only session and should ideally be done outside the child's hearing range. We would review standard and in-depth information about the child's development.
It is recommended that parents review childhood photos and videos to support their memory recollection.
The length of time is determined by the goal of the screening.

Step 4: In-person screening (60-90 minutes)

Christine will see the child in-person and screen them using a play-based method. It would be fun and doesn't feel clinical at all. Depending on their age, young children are likely to think they are at a playdate with a fun adult and are unlikely to know they are been assessed.
The length of time is determined by the goal of the screening.

Step 5: Report

If needed, a written report would be provided.

Christine charges $160 per hour and the whole process typically takes about 2-5 hours (including the report) depending on the complexity and the depth of the information gathered.
How would you like to pay for the developmental screening?*

Credit CardE-interacI would like to know more before deciding.Other
Client's Birthdate*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Emergency Contact*

First NameLast Name
Emergency Phone Number*
Please enter a valid phone number.

	Mon	Tues	Wed	Thur	Fri	Sat	Sun
9-12pm
12-4pm
4-7pm

New Client Inquiry Form

Information for the Developmental Screening