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Client Intake

Please take a moment to fill out the intake form below and someone from our team will be in touch with you shortly.
 

The questions answered here will share information about the learner/client who will be receiving services.

The completed form will be saved in the learner's file, or filed in our waitlist.


Please contact info@northernocs.ca with any questions or concerns.

What services are you interested in? Check all that apply.

Learner/Client Information

The questions answered here will share information about the learner/client who will be receiving services.

If you are a parent filling out this form for your child, are they capable of assenting to therapy? Are they aware that they may be enrolled in therapy? If so, are they willing and open to participating or have they expressed reservations or resistance to it? Assent is a term used to describe an individual's willingness to participate in treatment by persons who are by definition too young to give consent but who are old enough to understand the nature of the proposed treatment, the anticipated risks and potential benefits of the treatment to be able to make an informed decision.

Education History

Medical History

Therapy History

The questions answered here will share information about the learner/client's family.

 

If you are a parent filling this form out for your child, please complete the required questions in this section.

 

If you are an adult filling this form out to register yourself for therapy, please only complete the parent/guardian information if applicable. Otherwise, skip to the required questions at the end of this section.

Preferred Method of Contact:
Marital Status:
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Thank you, someone from our team will be in touch soon!

Family Information

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