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Information capturing form
* Indicates required question
Email
*
Record my email address with my response
Parent/guardian's first name
*
Your answer
Parent/guardian's surname
*
Your answer
Parent/guardian's email address (billing purposes)
*
Your answer
Parent/guardian's contact number
*
Your answer
Client's first name
*
Your answer
Client's surname
*
Your answer
Client's date of birth
*
MM
/
DD
/
YYYY
Client's email address (for content sharing and appointment invitations)
Your answer
Client's email contact number
Your answer
Client's email contact number
Your answer
Client's grade
Your answer
Client's school
Your answer
Please indicate the client's neurodiversity diagnosis below (if no formal diagnosis, please indicate areas of require support):
Please upload their assessments below (or email it to info@neurodiversitysupport.co.za)
*
Your answer
Option 1
Clear selection
Please indicate consent below:
*
I give NDS consent to capture and protect my personal data as stipulated by the POPI Act
I acknowledge a full consultation fee will be charged if not cancelled 24 hours in advance
I acknowledge that appointments made on a public holiday will have be charged double-rates
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