NEW CLIENT INtake form

Date of Birth
Date of Birth
Primary Contact *
Primary Contact
Contact Number *
Contact Number
Secondary Contact
Secondary Contact
Contact Number
Contact Number
Address *
Address
Area(s) of Concern (only check those that apply to your child) *
What services are you looking for (please check all those apply) *
If you are interested in groups, which group(s) do you wish to join?
SOCIAL THINKERS A social skills group that helps children explore social relationships with peers while learning important skills such as self-awareness, self-management, relationship skills, and responsible decision making. Groups: Ages 4-5; 6-7; 10-12) PEERS SOCIAL GROUP A 16-wk evidence based social skills intervention for motivated teens in middle school and high school who are interested in learning new ways of making and keeping friends. Parent training will be provided and parent participation is mandatory Groups: Ages 10-13; Ages 14-18. RESPONSIBLE ME An executive functioning group that teaches children how to manage their thoughts, actions, and emotions in order to complete tasks successfully, to plan and organize their time, and to monitor and manage their own behaviour. Groups: Ages 5-6; 6-7. GRAMMAR GURUS This is an expressive language and writing group that helps children improve their grammar skills, organize their ideas, and communicate more effectively. Group: Ages 7-8. READY FOR READING This is a group that helps children develop foundational literacy skills that are crucial for success in language arts and other academic areas. Group: Ages 5-6. STORY SUPERSTARS This group is designed to promote foundational oral language skills that are critical for success in school. Groups: Ages 4-5; 6-7. SPEECH BUDDIES This is an articulation group that helps children improve their speech skills so they can communicate more effectively at home and at school. Group: Ages 4-6.
(AFU, At Home Program, Variety, CKNW, etc.)
Ongoing Availability
What days and times are you available for your desired/ongoing service(s)? Please list your availability using the following format: (e.g., Monday: 9:00 to 12:00, Tuesday: all day, Wednesday: 4:00 to 5:00; 7:00 to 8:00)

CLINIC INFORMATION

13700 Mayfield Place, Unit 2145, Richmond, BC

Monday – Friday: 9AM – 6PM
Saturday & Sunday: 9AM – 6PM

*Please note that administrative support is not available on the weekends.

Email/Phone

General Inquiries: info@speechmeta.com / 604-285-1010