Referral Intake - Dr. Pure and Associates

Child's Legal Name(Required)

First Last

Child's Preferred Name(Required)

First Last

Date of Birth(Required)

What is your child's identified sex(Required)

Female

Male

What is your child/teenager's gender identity?

Residence(Required)

Street Address Address Line 2 City Province Postal Code

Covid 19 Vaccination(Required)

At the present time, we are asking that all children and adolescents who are eligible for vaccination re: covid 19 to be vaccinated in order to receive in person services.

Yes my child/adolescent is vaccinated.

No my child/adolescent is not vaccinated.

No, but I would be open to Telehealth Services (ZOOM, Telephone)

Parent Guardian Information

Parent / Guardian 1(Required)

First Last

Mailing Address if different from child's (PO Box if applicable)

Street Address Address Line 2 City Province Postal Code

Preferred Phone Number(Required)

Home Phone Number

Cell Phone Number

Work Phone Number

Parent / Guardian 1 Email(Required)

Enter Email Confirm Email

This form is configured to send a confirmation email to this email address.

Parent / Guardian 2(Required)

First Last

Mailing Address if different from child's (PO Box if applicable)

Street Address Address Line 2 City Province Postal Code

Home Phone Number

Cell Phone Number

Work Phone Number

Custodial Parents' Marital Status(Required)

Married/Common Law

Separated

Divorced

Widowed

Other (please explain below)

If separated/divorced from a biological parent, or "other" above, indicate custody agreement (joint/sole)

Siblings

1. Name

Date of birth

2. Name

Date of birth

3. Name

Date of birth

4. Name

Date of birth

5. Name

Date of birth

School / Daycare

Grade(Required)

French Immersion/ French School(Required)

Yes

If yes, is French the primary language spoken at home?

Yes

School/ Daycare Name(Required)

School / Daycare Address

Street Address City Province Postal Code

Phone

Fax

Teacher

First Last

Principal

First Last

Family Physician and/or Paediatrician (if applicable)

Family Physician(Required)

Address

Street Address Address Line 2 City Province Postal Code

Phone

Fax

Paediatrician (if applicable)

Address

Street Address Address Line 2 City Province Postal Code

Phone

Fax

Has this child been seen at our clinic in the past?(Required)

Yes

Are you currently referred to another facility for psychological services?(Required)

Yes

If yes, where?

Do you have medical coverage for psychological services?(Required)

Yes

If yes, name of insurance company

Please note the primary reason for referral to our office (please be thorough)(Required)

Name of individual completing this form(Required)

Relationship to child(Required)

Please Read: 2023 Intake & Referrals

Please Read: 2022 Intake & Referrals

Parent Guardian Information

Siblings

School / Daycare

Family Physician and/or Paediatrician (if applicable)

Please wait for a confirmation notice to appear once you have submitted your form.

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