Success in Steps - Intake Form
Thank you for contacting Success in Steps. We look forward to supporting you and your family!

Intake consultation take place virtually and are 50 minutes in duration.
If not already arranged, times and dates will be provided to schedule your session once the intake form has been completed.

Intake consultation fee is $150 +HST.
(For insurance purposes, an invoice is sent after attending the session, and then once payment is received, a receipt will be provided.)

Please complete the intake form below. 

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Email *
Do you wish to receive email updates in the future? *
Home Address *
Parents Info - Please provide the names of both parents. *
Name and age of your children *
Does your child have a diagnosis? *
If yes, what is the official diagnosis?
Please provide a brief description of your concerns. *
What have you tried in the past to resolve these challenges? *
Do these behaviours occur strictly at home or in various settings? *
Is your child aggressive to others or him/herself?  If, yes, please provide details with respect to how long, with whom and how often. *
Do these challenges occur with only specific people? If so, with who? *
When addressing these challenges and behaviours, are both parents on the same page in terms of follow-through? *
Parent/Caregiver #1 - What is your relationship with the child?
Clear selection
Parent/Caregiver #1- What do you consider your strengths or things that you do well? Example - patience, speak in a gentle voice. *
Parent/Caregiver #1- What do you consider an area of need? What do you feel you struggle with or would like help to improve? *
Parent/Caregiver #2 - What is your relationship with the child?
Clear selection
Parent/Caregiver #2- What do you consider your strengths or things that you do well? Example - patience, speak in a gentle voice.
Parent/Caregiver #2 - What do you consider an area of need? What do you feel you struggle with or would like help to improve?
Have you consulted with your family physician regarding these challenges? If yes, please share your physician's name along with their recommendations. *
How would you explain your child's personality? (e.g. has a strong personality, shy in nature, hard time accepting no) *
If your child attends school, has your child's teacher expressed any concerns? *
Are you working with any other professional services? (i.e., occupational therapist, speech-language pathologist, psychologist). *
How did you hear about our services? *
Required
Is there anything else you would like to share at this time? *
 48-HOUR CANCELLATION POLICY: 
Your appointment time is reserved for you and you alone. Our cancellation policy is in place to support the continuity of our work and commitment to the process of therapy/coaching.  If you are unable to provide at least 48 hours notice (not including weekends or holidays) when you cancel or if you miss your appointment, you will be charged the full fee for your session. If you have any ongoing questions about this policy, please speak to your service provider directly during your appointment. 
Thank you for taking the time to share this valuable information. You can expect a response within two business days.
Should you have any questions or concerns please feel free to email me at sylviacorzato@successinsteps.ca
**Please note, due to in volume of calls, emails are the best form of communication**
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