Book Now – Child

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


Child Client Contact Information


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

Child is currently in grade*:

Gender:

 

 

Parent/Legal Guardian Information


Parent/Guardian Marital status*:

 

Parent/Legal Guardian 1 Contact Information


Parent/Legal Guardian 1 Name:

Main Phone:

Email:

Street Address:

City:

Province:

Postal Code:

 

Parent/Legal Guardian 2 Contact Information

 

Parent/Legal Guardian 2 Name:

Main Phone:

Email:

Street:

City:

Province:

Postal Code:

 

Client Information

Please provide as much information as possible.


Request Details:

Assessment:

Group:

Therapy:

Learning Strategy:

Reading Pilots:

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?

Concerns with Reading?

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:

Tell us more about your concerns in the area of reading 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 our Privacy Officer at 403-686-9300 ext. 126 or by clicking here.