Club Aviva - Empowering Steps Intake Form

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Empowering Steps

Respondent (individual completing this form on behalf of the client)

You will receive a confirmation by email.

First name *

Last name *

×

Email *

Mobile

Participant Information

Participant

First name *

Last name *

×

Gender

Date of birth

Diagnosis(es) *

Other relevant past medical history

Medication(s)

Mobility *

Walking Non-walking

Speech *

Verbal Non-verbal

Vision limitations *

Yes No

Deaf/hard of hearing *

Yes No

Areas of concern *

Other ongoing therapies

How did you hear about us?

Guardian Information

Guardian(s), support staff, and other relevant personnel

click "+ Add" to include multiple individuals

Relationship

First name *

Last name *

×

Email *

Mobile

Gender

Who will be dropping the participant off at the assessment?

Who will be dropping off the participant at ongoing sessions?

Assessment Information

Funding availability *

MCFD Private Other...

Other

Therapies of interest *

Behaviour Intervention Movement Therapy Music Therapy SLP-Integrated Empowering Steps Physio-Integrated Empowering Steps Social Groups

Assessment availability

Assessments take approximately 45-60 minutes. Please enter as many days/times as you'd like by clicking "+ Add".

×

0 hours

Please accept all conditions.

Connect to fill this form

Please type in your email or mobile number. We will send you a connection code.

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98 Brigantine Dr 604-526-4464

clubaviva.ca comp@clubaviva.ca