Intake Application

Parent/Guardian Information
Parent/Guardian 1 Name*

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Parent/Guardian 1 Phone*
Parent/Guardian 1 Email*
Parent/Guardian 2 Name

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Parent/Guardian 2 Phone
Parent/Guardian 2 Email
Child Information
Child Name*

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Address*

Street Address

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CityProvince

Postal Code
Date of Birth*

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Gender Identification*
Daycare, Preschool, or School Name
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YesNoWaiting List
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If yes, please specify.*
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If yes, where?*
Current Therapists and Professional Services:
YesNo
If no, please describe the required level of assistance.*
YesNo
If no, please describe the required level of assistance.*
WordsGesturesPicturesAmerican Sign Language (ASL)Augmentative and Alternative Communication Device (e.g., TouchChat)Other
Services
1:1 Behaviour Intervention (ages 0-4 years)Social Skills Group (ages 5-11 years)Teen Club (ages 12-18 years)Gateway Learning Centre (grades K-12)
1:1 Behaviour Intervention is designed to give children the extra attention and repetition they may need to bridge developmental gaps and reach their full potential. Under the ongoing supervision of a Behaviour Analyst (BCBA), a Behaviour Interventionist works solely with your child, targeting goals outlined in their treatment plan. While every child's goals are unique, the domains typically targeted in 1:1 Behaviour Intervention include behaviour management, emotional regulation, academics, communication, play and leisure skills, and self-help skills.
Social Skills Group is designed for school-aged children who may benefit from extra support to learn how to make and keep friends. Evidence-based instruction and in-the-moment feedback are seamlessly integrated into intentionally chosen games and activities, creating a fun and engaging learning experience. Our mission is to empower children to confidently apply social skills in real-life situations and build meaningful connections both within and beyond the group.

Prerequisites: Verbal communication skills, self-sufficiency in a group setting, and motivation to participate.
Teen Social Club is a twice-monthly program designed to provide a safe, supportive environment for neurodivergent teens to be themselves, connect, and enjoy activities supported by qualified staff. Each session will focus on themed, interest-based experiences that provide the framework for connection and social interaction.

Prerequisites: Verbal communication skills, self-sufficiency in a group setting, and motivation to participate.
Gateway Learning Centre is an alternative education program tailored to children with autism and related disorders. While upholding the structure of a traditional classroom, we provide small class sizes, low student-to-staff ratios, and highly trained personnel. Our individualized curricula align with the B.C. Ministry of Education competencies, catering to each student's unique interests and learning style. Beyond academics, our mission is to equip students with essential problem-solving, communication, and life skills, empowering them for success beyond the classroom.

Prerequisites: Verbal communication skills, self-sufficiency in a group setting, and motivation to participate.
I confirm that all selected services are appropriate for my child based on age and prerequisites.
1:1 Behaviour Intervention 9:15-11:45 (0-18 years)1:1 Behaviour Intervention 12:30-3:00 (0-18 years)1:1 Behaviour Intervention 3:30-5:00 (6-18 years)Social Skills Group 3:30-5:00 (5-18 years)Acceptance & Commitment Therapy (ACT) (5-18 years)Learning Centre (Grades K-12)
What are your priorities for ABA therapy?*
When is your desired start date?*

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How did you hear about us?
Please note: We currently do not have any immediate openings and maintain a lengthy waitlist across all services. Wait times vary depending on service type, sibling priority, overall capacity, and other factors. Placement is not determined on a strict first-come, first-served basis.
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