Information Sheet for Child

Client Information Sheet for Child

    Client's First Name:

    Client's Last Name:

    Date of Birth:

    Gender: MaleFemale

    Home Phone:

    Other Phone:

    Email Address

    Street Address:

    City:

    Postal Code:

    Parent/Legal Guardian Name(s):

    Relationship to Client:

    Parent/Legal Guardian Address:Same as Above

    Primary Language: EnglishFrenchSpanishOther

    School Child Attends:

    Child's Grade:

    Private Insurance (ex. Blue Cross, Sun Life, Johnson): YesNo

    Referred to Therapist by:

    Reason for Seeking Therapy:

    Have you made an appointment with Mylène?
    If not please click "Make an Appointment" after submitting this form.

    I consent to sharing the following information with the psychologist and have fully read and signed the consent form explaining confidentiality.