Book Now – Adult






NOTE: All fields marked with a red * MUST be completed before you can submit. Give as much detail as you can.

Adult Client Contact Information


Date of Birth – Please complete (dd/mm/yyyy)*:

Gender:

 

 

Client Information

Please provide as much information as possible.


Occupation:

Are you currently employed?:

Are you currently a student?:

If you are currently a student, tell us what program you are in:

 

Request Details:

Assessment:

ADHD Coaching:

What are you hoping to achieve at CanLearn Society?:

What are your main concerns?: *:

 

Do you have:

Concerns with Attention?:

Concerns with Behaviour?:

Concerns with Learning?:

Concerns with Social/Emotional?:

Tell us more about your concerns in the area of attention:

Tell us more about your concerns in the area of behaviour details:

Tell us more about your concerns in the area of learning details:

Tell us more about your concerns in the area of social/emotional details:

 

Have you had a previous assessment? If yes, please provide dates and details of the assessment:*

Have you had a previous diagnosis? If yes, please any diagnosis made:*

 

CanLearn may transfer personal information to outside service providers that perform services on our behalf such as client relations management systems, or similar services. Some of these service providers may be located or store data outside of Canada, including in the United States. By providing personally identifiable information to us, you agree to the transfer of your personal information outside of Canada. More information about our privacy policies and practices can be accessed by contacting Laura Godfrey at 403-686-9300 ext. 126 or by clicking here.