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Initial Intake Form - ASD Group Inc.

Please complete all initial intake information to the best of your ability. 

You may leave a section blank or indicate 'not applicable', as appropriate, but please provide sufficient information around your referral concerns and service needs to allow us to allocate your referral to the appropriate clinician.  

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Email *
Child's Full Name & Preferred Pronouns *
Please note preferred name, as relevant (e.g., for Robert, Bobby)
Date of Birth / Age *
MM
/
DD
/
YYYY
Parent(s) / Guardian(s) Names *
Second Parent's Email (if applicable)
Has this child been involved in a separation or divorce? *
Please note that you may be asked to provide documentation regarding custody and medical decision-making for your child.
If you indicated a separation or a divorce, please describe the current parenting arrangements as it relates to custody (e.g., sole, joint, or shared custody) and medical decisions
Please note that you may be asked to provide documentation regarding custody and medical decision-making for your child.
Phone number(s) *
Home Address(es) *
Child's Grade *
Child's School/Preschool/Daycare (as applicable) *
Program 
Clear selection
What language does this child primarily speak at home? *
Referral Concerns (check all that apply) 
Describe your referral concerns as per above.   *
Helpful information to include : WHEN did concerns start?  WHO has concerns?  HOW impairing are these concerns in the child's and/or family's daily functioning?  
Has your child participated in any prior assessments (e.g., psychology, SLP, OT, other)? If so, please indicate the date(s) and whether any diagnoses have been given. *
Please send any assessment reports or supporting documentations to our office by emailing admin@asdgroupinc.ca. Please include in the subject line "Childs full name - Intake"
What services are you seeking?  (check all that apply) *
Required
Our private practice services are NOT reimbursable through provincial medical insurance (MSI). Your private medical insurance provider may offer reimbursement of some/all of your fees. Please indicate name of insurer AND coverage (i.e., amount of coverage per person, per year).

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