Intake

Child's Full Name

Child's DOB

Parents/Guardians' Full Name(s)

Email

Phone

Street Address

City

Postal

Province

Country

Please let us know what your area(s) of concerns are. * Required

Articulation (The clarity of speech sounds)

Expressive Language (The ability to use words/sentences, sign, gestures, AAC to communicate wants and needs)

Receptive Language (Understanding what is others say and what is read)

Literacy (Reading and writing)

Social Communication (Interactions with others, making requests, having conversations etc)

Fluency (Stuttering)

Please use this space to elaborate on your concerns, if needed.

I am looking for services...

Please indicate your availability. We will do our best to accomodate you!

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Please use this space to provide times that you are available (e.g. "weekdays after school" or "Saturday AM")

Thank you for taking the time to fill out this intake form!

416-294-9882

2077-30 South Unionville Ave, Markham, ON, L3R 5M3

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