Child Intake Form

Child’s First Name

Child’s Last Name

Date of Birth

Gender

Grade

School Board

Name of Person Inquiring

Relationship to the Child

Phone Number

Preferred Contact Method:

Email Phone (I consent to voicemail) Phone (I do not consent to voicemail)

Service (Please select one)

Reason for the assessment:

Does the child live with both parents full time?

If not, are there any legal matters related to separation, divorce, custody, or access that are currently pending before the court?
Please note: We do not work with high-conflict or court-involved family separation or divorce cases involving minors to ensure you receive the most appropriate and specialized care. We can provide you with a referral to a more suitable practice, if needed.

If seeking gifted testing, has the child undergone intellectual/gifted/IQ testing previously?

If yes, please specify which test and the testing date

Referred by:

Please specify

Please be advised that email and online contact forms do not guarantee secure communication. While we take reasonable steps to protect your data, the confidentiality of information transmitted over the internet cannot be guaranteed. It is recommended that you limit highly sensitive information in this initial inquiry.

Please visit our Services and FAQ pages for additional information about our process, fees, and more.

My use of email and/or this contact form indicates my acknowledgment and acceptance of these potential risks.