Geneva Centre for Autism Intake Form

Online Intake Form

Welcome to Geneva Centre for Autism! Let's get started!
Please note that Geneva Centre does not provide diagnoses. If you wish to hear more information about obtaining a diagnosis, please contact intake@autism.com.
Are you new to Geneva Centre?*

YesNo

Contact Information
Your Full Name*

First NameLast Name
How are you related to the client? *
What is the best telephone number to reach you?*
Please enter a valid phone number.
What is the best email address to reach you?*
example@example.com
What is your primary language?
If the primary language was not listed, please enter it here.
Do you need an interpreter?

YesNo
What is your address?*

Street Address

Street Address Line 2

CityProvince

Postal Code

Client information
What is the client's name?*

First NameLast Name
If the client known by a different name, please specify below
What is the client's date of birth?*

YearMonthDay
Date (yyyy-mm-dd)
Enter which pronoun the client would like others to use when talking to or about the client

Client Information

Please confirm the information below is correct OR please fill in the client information.
Client's Phone
Client's Email Address*
example@example.com
Client's primary language
Client's other language
Does the client need an interpreter?

YesNo
Clients' Address

Street Address

Street Address Line 2

CityProvince

Postal Code

Upload Diagnosis (Optional)

Please SKIP THIS STEP if you are not looking for funded children’s services or are unable to upload.
To be eligible for funded services through the Ministry of Children, Community, and Social Services (MCCSS), clients must live in the GTA (postal code starting with M) and have a formal diagnosis of Autism Spectrum Disorder. Please attach a copy of the diagnosis which should include the following information:
- Client’s name
- Client’s date of birth
- Date of diagnosis
- Must state: “Was found to meet the criteria of a diagnosis of Autism Spectrum Disorder” or “Meets DSM 5 criteria for Autism Spectrum Disorder (ASD)”
- Doctor’s signature
If your diagnosis is password protected, please email the password to intake@autism.net.
Diagnosis attached

Browse Files

Cancelof

Since you are an existing client, no need to fill this form out. Instead, please contact intake@autism.net.
Should be Empty:

Contact Information