Assessment Intake Form

Assessment Intake Form
Please complete this form only if you are ready to schedule your assessment. If you have questions you want answered before moving forward, please contact Melanie Reader at mreader@foothillsacademy.org.

Thank you for your interest in our assessment services. To summarize, our assessments:
- Cost $2,250.
- Are completed within a training facility model, under the supervision of fully registered psychologists
- Typically take 6-8 weeks to complete
- Focus on identifying barriers to learning. Please note that our staff are not trained in the gold standard tools used for the identification of Autism Spectrum Disorders. If this is your primary concern, please contact mreader@foothillsacademy.org for recommendations of other agencies that may be better suited for you.
- Unless requested directly to your assigned clinician:
  - Intake sessions will be done through virtual means, using the Zoom platform. Consent forms will be sent electronically.
  - Interviews, as well as the final debrief session(s), will also be completed using the Zoom platform
- Please note that all testing sessions are completed in-person at Foothills Academy.
If you are still interested in starting an assessment with us, we need the following information. Please fill in the form below. Once submitted, you will receive an appointment confirmation by email with your appointment details.

PLEASE NOTE: We have very limited availability for Saturday appointments. Please indicate alternative days that would work for your schedule.
Your name*

First NameLast Name
E-mail*

Confirmation Email
Phone Number:*

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityProvince

Postal
How did you hear about Assessment services at Foothills Academy's Community Services?

My child attends/attended Foothills Academy schoolMy child has participated in other Community Services programs (like Read/Write & Math or Camp Amicus)Friend or family recommendationPhysician referralTeacher referralGeneral word of mouthFoothills Academy websiteInternet searchCalgary's ChildOther
Who is the Assessment for?*

First NameLast Name
Date of Birth*

MonthDayYear
mm/dd/yyyy
Date of Birth*

MonthDayYear
Gender*
Age*
Client's Grade (if applicable)
Client's School (if applicable)*
Age of Client

If you are booking this assessment for someone else who is over the age of 18, we are obligated to contact them directly regarding their intake and assessment details. Please provide their email and phone number here. If your child would like you involved to provide relevant background information and support, they can share the booking details with you
Client Name

First NameLast Name
Client Phone Number

Area CodePhone Number
Client Email
example@example.com
Custody Details for Children under 18 Years of Age
If the individual being assessed is under 18 years of age, is there a formal or informal custody arrangement in place for this child where both parents have decision making rights?*

YesNoNot applicable
Is the custody arrangement formal or informal?

FormalInformal
If there is a custody arrangement, please detail.
Please note that in joint/shared custody situations, BOTH parents' consents are required before testing can start with the child.
If applicable, please provide the additional custodial parent's name, email and phone number.
Additional custodial parent's name

First NameLast Name
E-mail
example@example.com
Phone Number:

Area CodePhone Number
If there is a court order demonstrating you have sole custody of the child, you can upload a copy of the court order document here, or bring it to your intake session. We will require a copy before testing can begin.

Upload a File

Cancelof
Please outline your concerns or reasons for wanting a psycho-educational assessment at this time.*
Many private and employer benefit plans provide coverage for psychological services. It is recommended that parents/clients discuss their coverage with their insurer to determine whether our services will be covered. That is, it will be identified on the receipt who provided the service, including their position with us (e.g., intern, Registered Provisional Psychologist, psychometrist). All clinicians are supervised by Registered Psychologists, and the Manager of Assessment & Intervention, who is a fully Registered Psychologist in the province of Alberta, signs all receipts.

Please note: Any costs for such services as psycho-educational assessments, counselling, or consultation that are not reimbursed through insurance may be claimed as a medical expense upon completing your income tax.

At this time, due to the overwhelming demand for financial assistance, we can only consider bursary requests for psycho-educational assessments for children and youth.
With the above information in mind, do you require a bursary application package?

NoYes, send it to my email listed above
In the past year, have any family members living in the same household received any bursary assistance? If so, please check all applicable programs a bursary was received for:

Foothills Academy school programRead/Write or Math programPsycho-educational AssessmentCounsellingLet's Be Social programActing Social programSurvive & Thrive in Junior High programGirls Only programCamp AmicusAmicus Recreation
What is the name(s) of the person(s) the bursary was for?
Please note that if bursary assistance is required, this step must be completed prior to the start of the assessment. You will be contacted once your application is reviewed by our business office.
Parent intake sessions will occur virtually, using the Zoom platform. Instructions will be provided. Scheduling for these sessions can be flexible based on clinician availability. Do you have any time preferences or limitations?

Please indicate your day and time preferences for your child's testing sessions. Testing sessions are booked based on clinician availability. Sessions are typically booked Monday to Friday starting at 9:00AM or 1:00PM. While we cannot guarantee availability, we will try our best to meet your preferences. PLEASE NOTE: In some cases, we may book on Saturdays. The majority of our assessments are done Monday-Friday. *

	9:00a.m.	1:00 PM
Monday
Tuesday
Wednesday
Thursday
Friday

Do you have any questions or comments?
Should be Empty:

Assessment Intake Form

Age of Client