New Client Intake Form

Please complete the intake form below and we will get in touch with the next steps.

Intake Form

General Information:

Please fill out the following intake form to the best of your ability. I realise there may be information that you do not recall or have access to; please do the best you can. Thank you.

Emergency contact information:

Purpose of Professional Contact:

As we begin our work together, it may be helpful for me to know some basic information about you, your history and your concerns. Please take a few minutes to answer these questions the best you can. Anything you share will be kept confidential.

Medical History & Diagnoses:

Family History:

Developmental History:

Sensory Profile:

Psychological Profile: