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
Client DOB (dd/mm/yy):
MM
/
DD
/
YYYY
Client Current Age:
Assessment clients: Our assessments are conducted primarily in English, which means that for test results to be valid the client should be able to fully understand and express themselves in English with ease. Academic testing can be done in French for clients attending school in French. 
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Client Language of Learning or Work
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Reason for Seeking Services: Please describe what is bringing you/your child for services. *
Service Requested:
Has the client received any prior diagnoses? If yes, please list. 
If available, I am interested in working with a trainee for up to 25% reduction in costs.
Client School and Grade and/or Occupation
Parent/Guardian Name
Parent/Guardian Email
Parent/Guardian Phone
Parent/Guardian #2 Name
Parent/Guardian #2 Email
Parent/Guardian #2 Phone
For clients under 16: Parents & Custody arrangement
If parents are separated: 
Where did you hear about me? *
Required
If another provider or school, name of person/school who sent you to me:
Any other information you would like us to know at this stage?
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