Enquiry Form
Let us know how we can help you!
Full Name:
*
First Name
Last Name
Parent's name (for children)
First Name
Last Name
Other parent's name
First Name
Last Name
Age:
*
If you are over 18 and do not wish to say, please just type 18+
School of enrolment: (for child)
Contact Number
*
Please enter a valid phone number.
Email Address
*
example@example.com
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please share a brief reason for referral:
*
Please indicate how we can support you, all potential clients are offered a comprehensive intake call of 15 minutes:
*
ADHD Assessment
Autism Assessment
Specific Learning Disorder Assessment (i.e., Dyslexia and Dysgraphia)
Cognitive Assessment
Individual Counselling Therapy
Advice about my assessment needs
I would like a 15 minute call back to discuss my needs, I am not sure what we need.
If you already have a Mental Health Care Plan, you can upload it here:
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