Connect with us:

For new clients, please fill out the form below. You will receive a call within 3 business days from our team if we have an opening that matches with your listed time. If you have not heard from us after 3 business days, it is likely that we do not have availability at this given time. Thank you.

Name of Client (First & Last Name)

Date of Birth

YYYY

Age

Primary Contact

First Name

Last Name

Contact Number

(###)

###

####

Email Address

Please list all of the language(s) spoken by child or language(s) used with child:

Describe your questions and concerns regarding your child's speech and language development and indicate any previous diagnosis:

Does your child display any major behavioural issues at home? (Yes/No. If yes, please describe.)

REQUIRED - Ongoing Availability

This helps us connect you with a clinician who can match your schedule. Please list your availability using the following format: (e.g., Monday: 9:00 to 12:00, Tuesday: all day, Wednesday: 3:30 to 6:00)

Monday:

Tuesday:

Wednesday:

Thursday:

Friday:

Saturday:

Limited availability

Sunday:

Limited availability

Service Delivery Preference

In-Person

Teletherapy

No preference

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

Extended Health Benefits / Private Pay

Autism Funding (AFU)

At Home Program

Variety / CKNW

Other Funding Sources

Referral Source

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

For new clients, please submit the form above as our admin team does not take referrals over the phone.

To reach our administrative staff for billing questions, please contact us at info@speechmeta.com or 604-285-1010.