Client's information:

Referral is for:

Assessment inquiry:

First name

Last name

Birthday

Year

Month

Day

Phone

Email

Parent's information (if client is child/dependent):

Parent's name

Our waitlist is rapidly growing, with a current wait-time of 2-3 months. We will contact you within 5 business days of receipt of your referral with possible assessment dates. In order to provide prompt support and maintain a short wait for you, we remove individuals from the waitlist if they do not take an available date within a 4 month time-frame. Please 'check' this statement as your understanding of this policy.