Assessment Waitlist Form

Thank you for your interest in our services. Please complete the following form to add yourself to our assessment waitlist. Once we receive your information, we will send you an email confirming this and provide you with a list of resources while you wait. Please check your junk folder. If you have not heard back from us within 1-week of completing this form, please contact us at 604-398-3837 extension 0. Please note that our current estimated wait times for autism assessments are 4-6 months, and 1-2 months for psychoeducational assessments.

Autism assessments for children under the age of 6 - We require that the child has already had their pediatrician assessment and SLP assessment before we complete the assessment. You can still add your child on our waitlist, however, it can delay your assessment with us.

If your family requires separate appointments for the parent interviews, additional feedback sessions, or additional testing appointments, this additional time will be billed accordingly in addition to our regular assessment fees. This will be discussed with you prior to booking the extra appointments.

The information collected here is to add your name to Reframe Counselling & Assessment Clinic Inc. waitlist for assessment only (Psych-ed, Autism assessment, ADHD assessment, mental health assessment). If you are looking for counselling services, please complete our general contact form found HERE. Your information is confidential and will not be shared outside of our practice unless required by law. Please direct any questions to info@reframepsych.com or call 604-398-3837 extension 0.

Client Name

First Name

Last Name

Date of Birth

YYYY

Sex

Pronouns

How did you hear about us?

Email Address

Phone Number

(###)

###

####

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name of Guardian (if client under 19 years old)

First Name

Last Name

Guardian Relationship to Client

Name of Second Guardian (if applicable)

First Name

Last Name

Second Guardian Relationship to Client

Second Guardian's Email (if guardians not living together)

If guardians are divorced or separated:

Name Of School (if applicable)

Teacher Name (if applicable)

First Name

Last Name

Teacher Email (if applicable)

Teacher Phone Number (if applicable)

(###)

###

####

Do You Have Third Party Funding? (i.e. school, Variety, Jordan's Principle, FNHA, etc.)

What Service Are You Looking For?

Please List Any Assessments Completed to Date:

Do you have someone specific you would like to complete the assessment or would you like to see the first available assessor? (you may need to wait longer for a specific assessor)

For autism assessments, what is your child's current language level?

Non-verabl

One word phrases

Two-to-three word phrases

Full speech

For Autism Assessments With Children Under 6, Have They Been Seen By A Pediatrician?

For Autism Assessments With Children Under 6, Has A Speech And Language Assessment Been Completed?

What Is Your Hope For This Assessment For You Or Your Child?

Do You Have Additional Comments Or Questions?

Assessment Waitlist Form

Reframe Counselling & Assessment Clinic Inc.

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