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OUTSIDE THE BOX SPEECH AND LANGUAGE
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Intake Form
First Name
Last Name
Email
Code
Phone
Child's Name
Address
Which of the follow services are you interested in
In-home supports
Online Sessions (Telehealth)
Parent consultation/coaching
I'm unsure and would like to discuss this further
Do you have an FSCD contract in place?
Yes, Specialized Services Contract (SS)
Yes, the developmental-behavioural Aide Contract (DBA / BDS)
I am unsure
No
Does your child have a current diagnosis (e.g. Autism Spectrum Disorder, Global Developmental Delay (GDD), ADHD, Cerebral Palsy etc.)?
Please share some of your child's interests and strengths
What is the best time of the day to contact you?
What is the best method to contact you?
Please identify your preferred days/times you are available for sessions. *Please note that these times are not guaranteed and may be subject to a waitlist*
Submit
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