Client Intake Form

Please complete our Client Intake Form if you are interested in learning more about our services.

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"*" indicates required fields

CLIENT INFORMATION

Child/Youth First Name*

Child/Youth Last Name*

Child/Youth Date of Birth*

City/Town*

Language*

Parent First Name*

Parent Last Name*

Email Address*

Telephone*

Preferred Contact Method

Email

Phone

IS THE PATIENT REGISTERED IN THE ONTARIO AUTISM PROGRAM?*

Yes

No

PLEASE SPECIFY YOUR RELATIONSHIP TO THE CHILD/YOUTH (I.E. PARENT/GUARDIAN, SERVICE PROVIDER, ETC.)**

PLEASE ADVISE WHICH SERVICES YOU ARE INTERESTED IN**

Consent

BY COMPLETING THIS FORM, YOU CERTIFY THAT YOU ARE THE PRIMARY CAREGIVER OF THE CHILD/YOUTH WHICH THIS FORM IS BEING COMPLETED FOR. IF YOU ARE NOT THE PRIMARY CAREGIVER, YOU CONFIRM TO HAVE CONSENT FROM THE PRIMARY CAREGIVER TO COMPLETE THIS FORM. IF YOU ARE NOT THE PRIMARY CAREGIVER OR DO NOT HAVE CONSENT FROM THE PRIMARY CAREGIVER AND ARE LOOKING TO INQUIRE ABOUT OUR SERVICES, PLEASE CONTACT PAM GILES AT 613-355-3303.

I GIVE CONSENT ON BEHALF OF THE PATIENT

Yes

No

WOULD YOU LIKE TO RECEIVE INFORMATION OF PORTIA’S SERVICES AND PRODUCTS THROUGH EMAIL?

Yes

No

Comments

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