Child/Youth Appointment Request
Cochrane Consulting
Name of Child/Youth
*
First Name
Last Name
Age of Child/Youth
*
Name of Parent/Guardian
*
First Name
Last Name
Contact E-mail
example@example.com
Contact Phone number
What led you to consider psychoeducational testing for your child?
What question(s) are you hoping this assessment will answer?
Are there any specific supports you are hoping this assessment will assist you in accessing?
Have you ever wondered if your child has one or more of the following conditions?
Learning Disorder/Disability (e.g., Dyslexia)
ADHD
Intellectual Disability
Anxiety
Depression
Autism
Please provide an explaination for each of your selections.
Does your child attend French Immersion?
Yes
No
How would you like to be contacted?
Telephone
Email
Submit
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