West Coast Centre for Learning - Psychoeducational Assessment Expression of Interest

Psychoeducational Assessment Expression of Interest

Child

First name *

Last name *

Gender *

Date of birth *

Grade *

Primary language spoken in the home and any other languages:

What school does your child go to? *

Parent/Guardian

You will receive a confirmation by email.

Relationship

First name *

Last name *

Email *

Mobile *

Address *

City *

Country *

State/Province *

Zip/Postal code *

Other parent/guardian

Relationship

First name *

Last name *

Email *

Mobile *

Address if different from above:

Please select your preferred location. *

S. Surrey: 401-3211 152 Street, Surrey, BC Victoria: 301-3450 Uptown Blvd, Victoria, BC

What is your preferred method of communication? *

Phone Text Email Zoom

What problems have been concerning you?

What interventions have you already tried, if any? ie. tutoring, vision therapy *

Yes No

If yes, please specify

How did you hear about the West Coast Centre for Learning? *

Service provider (Pediatrician, General Practitioner, Psychologist, Counsellor) BC Psychological Association Internet Search Family / Friend Social Media Other

If by a family/friend or professional, please list their name below. If by other, please specify.

Would you like to receive our newsletter with helpful parenting tips, program information, and special offers. (You can unsubscribe at any time) *

Yes please! No thanks

Will you be accessing funding to pay for the program? *

First Nations Health Authority Jordan's Principle Variety Funding Autism Funding School Funding Bill me privately Other

If other, please specify:

Will you be utilizing extended health benefits? *

Yes No Unsure

Please list any other questions, comments or concerns that you may have.

Thank you for choosing West Coast Centre for Learning, we look forward to connecting with you soon. A member of our team will reach out to you shortly with further details.

Please note that service availability depends on clinician availability and client needs. Should you have any questions in the meantime, please don’t hesitate to contact us at info@wccl.ca or (778) 839-5515

By submitting this form, you consent to West Coast Centre for Learning collecting and using your information to respond to your inquiry. For details on how your data is stored and protected, please review our Privacy Policy.