Let’s Connect.

Name of Client *

First Name

Last Name

Client's Date of Birth

MM

DD

YYYY

Primary Contact *

First Name

Last Name

Phone # *

(###)

###

####

Preferred Clinic Location (Free Parking Available at Both Locations)

RICHMOND (Near Ikea Richmond)

VANCOUVER (City Square Mall)

No preference – we’re happy to go wherever is available first

Do you wish to use third party funding? If so, please indicate below:

Extended Health Benefits

Autism Funding

At Home Program Funding

CKNW / Variety Funding

Home School Funding

We will do our best to connect you with an SLP on our team. In the event that our SLPs do not have availability for ongoing or in-person sessions, please indicate your interest in the following options. Selecting these alternatives can help us provide you with timely and effective care:

I am interested in the option of connecting with a therapist who can provide online therapy sessions for my child if there are no in-person spots at the moment.

I am interested in the option of doing a consultation and a block of therapy (6-10 sessions depending on SLP's availability) if my availability does not match with the SLP's schedules.