Psychoeducational Assessment Intake Form Child's Name * First Name Last Name Date of Birth MM DD YYYY Parent(s) Name First Name Last Name Are parents together? Separated? If separated, please indicate whether both parents agree to this assessment. Together Separated Both parents agree to this assessment. Best phone number to reach you Country (###) ### #### OK to leave voicemail? Yes No Email Is it OK to email? Yes No What are the main areas of concern for your child? Some examples might include learning challenges (i.e., reading, spelling, math), giftedness, attentional concerns, or behavioural problems. What questions are you hoping to have answered through this assessment? Is there a particular psychologist that you are hoping to work with? Any mental health challenges or stressors we should be aware of? What type of school program is your child/youth enrolled in? English French Immersion French Thank you! Our office manager will be in touch within a week to walk you through the next steps.
