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We look forward to meeting you! Please complete this form. We will review your application and contact you with next steps or to request additional documentation.

Please note that we predominantly see clients for autism and psycho-educational assessments.

Child’s full legal name *

Child’s date of birth *

Parent/Guardian’s Legal First Name *

Parent/Guardian’s Legal Last Name *

Phone

Email *

Please indicate what type of service you are seeking

• Psycho-educational Assessment
• Autism Assessment
• Psych-ed & ADHD Assessment
• Psych-ed & Autism Assessment
• Speech and Language Assessment
• Social Skills Therapy Group
• Parent Support Group
• Consultation
• Other (please specify below)

Other type of referral

Who referred your child for this assessment?

Has your child seen a pediatrician?

Who provide child

If yes, please provide their name

Has your child been evaluated by a speech pathologist? (please provide details if your child is under 6)

Please provide a brief description of your child and why you are seeking this assessment.

Submit

Please watch for an automated reply stating that we have received your request and allow us up to five business days to review it. We promise to get back to you.

Thank you

Fax: 604.291.7879 Email: info@akiraclinic.ca
204-4279 Dawson Street; Burnaby BC V5C 4B3