Intake form for clients under 19

I assess children and youth under 19 through ABLE Developmental Clinic in Surrey, BC. When you send this form, it comes to me by email, with your answers attached as a PDF, and I'll contact you about next steps. I won't share your information with ABLE until you have agreed to it.

No Client Portal account is created.
Your answers save as you go on this device until you send the form, then they're cleared.
This website doesn't keep a copy of your form once it has been delivered (privacy policy).

Is this for someone 19 or older? Please use my regular intake form instead.

Getting Started

Two quick details so I know who I’m hearing from, and the email address I’ll reply to.

Person Completing This Form

Date

Where I can reach you

Email address

I’ll reply to this address. It doesn’t create an account, and it isn’t saved in the draft on this device.

Client Information

Tell me about the person who will be seeking care.

Legal Last Name

Legal First Name

Preferred Name

Pronouns

Date of Birth

Age

Gender

Primary Language

Secondary Languages

Ethnicity / Culture

City or Town of Residence

Province of Residence

Postal Code

Previous Medical Diagnoses

Previous Psychological Diagnoses

Chronic Health Conditions

Allergies

Hearing

Vision

Previous Assessments and Dates

Professionals You Work With, and for How Long

If the Client Is a Child, Youth, or Dependent Adult

Parent / Guardian Legal Name

Preferred Name

Relationship to the Client

Contact Information

How I’ll reach you when an appointment becomes available. I’ll use the email address you entered above.

Phone Number

Preferred Contact Method Email Phone Text Only Either

Preferences and Access Needs

So the process works for the way you or your family actually function.

Preferred Appointment Format

General Availability and Preferred Times

Communication Preferences, Accessibility Needs, or Accommodations

Is There a Deadline or Time-Sensitive Reason for Your Request?

Payment and Benefits

How do you expect to pay for appointments? Please select all that apply.

Payment Method

Out of pocket Extended health benefits or private insurance Funding through an organization or program Unsure Other

If You Plan to Use Other Funding, Please Name the Organization or Program

A note on benefits. If you plan to use benefits, please check with your provider about coverage for psychological care or assessment, any referral requirements, and your available coverage amount. Coverage varies by plan, and you are responsible for fees that are not covered.

Do You Have Any Specific Invoice or Receipt Requirements?

Yes No Unsure; I will check with my insurer or funding provider

If Yes, Please Describe What Is Required

Please let me know about these requirements before your first appointment so we can clarify what can be provided. Invoices and receipts must accurately reflect the care provided and the person who received it.

Waitlist Acknowledgement

Please read and check each of these before sending. How your information is collected, kept and protected: privacy policy.

Acknowledgements I consent to this form, including health information, being sent by email to Dr. Dmyterko at info@julianed.ca. I understand it is not kept on this website once it has been delivered, and that it is not shared with ABLE Developmental Clinic or anyone else without my consent. I agree to be contacted about my request and appointment availability. I understand that submitting this form does not guarantee an appointment or establish a psychologist–client relationship. Fit and availability will be confirmed before an appointment is booked. I understand that this form is not monitored for urgent support and should not be used to request emergency care. If you are in an emergency, call 911.

What to Expect Next

When you send this form, it comes to me by email, with your answers attached as a PDF. I will review it and contact you about next steps. Children and youth are assessed through ABLE Developmental Clinic in Surrey, and I won’t share your information with ABLE until you have agreed to it.

Questions about the waitlist can go to info@julianed.ca. My website doesn’t keep a copy of your form once it has been delivered, so print or save one before you leave the page if you’d like to keep it.

Is There Anything Else I Should Know?

0% complete

Getting Started

Client Information

Contact Information

What Are You Seeking?

Preferences and Access Needs

Payment and Benefits

Waitlist Acknowledgement

What to Expect Next

Is There Anything Else I Should Know?

Thank you.