Seeking Counselling Support? Book now with one of our counsellors. Online and in-person options are available. We have three locations to serve you. Due to an influx of booking requests, expect up to one week of wait time following your submission to be contacted by a clinic representative. Seeking a Psycho-educational, ADHD Assessment, or Career Assessment? Fill in the boxes below and a representative will connect with you to complete the booking. Which location do you want to make a booking at?*Select...Downtown Victoria (Parkside)SidneyWestshore (Langford)Which service do you want to make a booking for?*Select...Psycho-educational AssessmentAdult Psycho-educational AssessmentAdult ADHD AssessmentCareer AssessmentWho is this booking for?*Select...Myself (over 19 years old)My child (under 19 years old)My adult child (over 19 years old)Other (student, family member, etc)If completing the form for yourself, please provide your information. If completing the form for someone else/ your child, please provide their information. Informed Consent*We practice Informed Consent which requires the legal parent(s) or guardian(s) to authorize Consent for Services. Are you an intact family or co-parenting at separate addresses?Select...Intact family or non applicableSeparated with full parental rightsCo-parenting with consent from my child's other parentCo-parenting and needing to obtain consentParent/Guardian Name(s)*First NameLast Name Use the (+) button to add another row.Name* First Last Email Address* Phone Number*Address* Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Child's Name* First Last Date of Birth* Year Month Day Provide your date of birth if this booking is for yourself, otherwise provide the date of birth for the person this booking is for.School GradeSelect...N/APre-KKindergartenGrade 1Grade 2Grade 3Grade 4Grade 5Grade 6Grade 7Grade 8Grade 9Grade 10Grade 11Grade 12Post-secondaryName of the school attendingIs your child's school a Francophone school?NoYesIs this a reassessment?*NoYesWhat year was the previous assessment conducted?*Where was the previous assessment conducted?*Please specify if the previous assessment was conducted through one of our offices or somewhere else.Would you like to be added to a cancellation list?NoYesIf assessment appointments at your selected location open in the time before your intake, we will contact you to offer the availability. Cancellations are first come, first serve. We will contact the cancellation list in order of submission; if the assessment works for you, please let us know ASAP. If you cannot take a cancellation availability, you will remain on the cancellation list.Will this be covered by a third-party payer?*NoYesThird-party payers may include: Jordan's Principle, Variety, SelfDesign, Heritage Christian, Regent Christian, Kleos, etc. This does not refer to your extended health benefits or medical insurance as we do not direct bill.Do you have any notes or comments?Anything you would like to pass along regarding the assessment? If you called the office first to discuss please make note of the phone call. CommentsThis field is for validation purposes and should be left unchanged.