Intake Form
Please complete our Intake Form.
An intake specialist will reach out to you within a week.
Client Name :
Age
Contact Name (if different from Client Name)
Email
Phone :
Therapy Requested:
Physiotherapy
Occupational Therapy
Speech Therapy
Speech/OT Assessment for potential Autism Diagnosis
Diagnosis (if known):
What are your main concerns or reasons you are seeking therapy?
Which location do you prefer:
Please select a location
Abbotsford
Chilliwack
Coquitlam
Langley
Surrey
Would you consider going to an alternate location to receive services sooner?
Yes
No
Would you prefer:
In Clinic Sessions
Community Sessions (at your home, or another facility)
Virtual Sessions
Funding:
Private Pay/Private Insurance
At Home Program
Autism Funding
Variety/CKNW
Home School
Other
Other
Is there any other information you think is important for us to know?
Send
