Contact - Akira Clinic

Please complete this form to request an appointment. At this time, we are only seeing clients for assessments (e.g., psych-ed, autism, CLBC) and are not seeing clients for therapy.

Once you complete this form, your application will be reviewed and we will contact you with next steps or to request additional documentation.

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

Consultation

Other (please specify below)

Other type of referral

Who referred your child for this assessment?

Has your child seen a pediatrician?

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.

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YOU WILL RECEIVE AN AUTOMATIC REPLY THAT WE HAVE RECEIVED YOUR REQUEST. PLEASE ALLOW 3 TO 5 BUSINESS DAYS FOR US TO REVIEW YOUR REQUEST.

Thank you

Fax: 604.291.7879 Email: info@akiraclinic.ca 405 - 3701 Hastings Street, Burnaby BC V5C 2H6

Fax: 604.291.7879 Email: info@akiraclinic.ca
405 - 3701 Hastings Street, Burnaby BC V5C 2H6