Teacher Referral Form
  • Student's Date of Birth*
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  • We are a virtual-first clinic with secure video sessions available across Ontario, along with some in-person options. Our specialized multidisciplinary services and integrated treatments involve allied health professionals are not covered by OHIP. Fees may be covered by private insurance.

  • Area of Concerns have been observed in the following areas:

  • ACADEMICS
  • BEHAVIOUR
  • EMOTION REGULATION
  • SOCIAL FUNCTIONING

  • Teacher/School Information

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  • I acknowledge that I have received consent from the family of the above-named student to share this information with the Possibilities Clinic.

  • Date
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  • Should be Empty: