Julia Ryan Psychology Request for Services
Thank you for your interest in working with us! 

Please make sure to read the information on our website before completing this form, as it contains important details about our services.

Please fill out all applicable sections; If there are sections missing this may cause delays.

If this is for an individual 16yo+, please ensure the client themselves is involved in completing this form.

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Name of person completing form and relationship to client
Client Name:
Client email *
Client phone
How would you like to be contacted?
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Client DOB (dd/mm/yy):
MM
/
DD
/
YYYY
Client Current Age: *
Reason for Seeking Services: Please describe what is bringing you/your child for services. It is ideal to give a few sentences of the concerns you would like to have addressed. *
Format Preference: *
Required
Location where you currently live: *
Required
Availability:
Is there anyone specific you are looking to work with?
Have you/your child (the client) received any prior diagnoses or mental health service? If yes, please provide details. *
Cost considerations
I also am looking for an assessment
Client School/Grade and/or Client Occupation
For clients under 16: Parents & Custody arrangement
For children and youth under the age of 16 whose parents are separated:
Parent/Guardian Name
Parent/Guardian Email
Parent/Guardian Phone
Parent/Guardian #2 Name
Parent/Guardian #2 Email
Parent/Guardian #2 Phone
Did someone refer you/your child for services? If yes, please list.
How did you hear about Dr. Julia Ryan and her team? 
Please click if any of these apply to how you heard about our services:
Any other information you would like us to know at this stage?
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