Contact - Akira Clinic

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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

Please indicate what type of service you are seeking

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.

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 204-4279 Dawson Street; Burnaby BC V5C 4B3

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