New Client Intake Form

New Client Intake Form

Please fill out this form to help us understand your needs and schedule your appointment.
Child's Full Name

First NameLast Name
Child's Date of Birth

DayMonthYear
Name of School/Daycare
Grade in school
Parent/Guardian Name
Parent/Guardian Contact Details
Please enter a valid phone number.Format: 0000 000 000.
Parent/Guardian Email Address
example@example.com
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Preferred Contact Method
What services are you interested in?
Reason for seeking therapy / concerns
Diagnosis / Relevant Medical or Therapy History

Please share any diagnosis details, past therapy, medications, or other relevant medical background.
Diagnosis / Relevant Medical or Therapy History
Preferred Days for Initial Assessment
Preferred Days for Therapy Sessions
Should be Empty:

Diagnosis / Relevant Medical or Therapy History