top of page

Home
Services
About Us
Contact
More

Use tab to navigate through the menu items.

Intake Form

Please fill in the form below to let us know which service you are interested in and any questions you have. We will get back to you within a week.

Parent First Name*

Family Last Name*

Phone number*

Email*

How old is your child?*

Primary reason for seeking services*

Child's Strengths and Interests*

Communication Method *

Examples: Vocal, PECS, AAC, ASL

Funding/Insurance Type*

OAP Funding

Private Insurance

Other

Please list any challenging behaviours *

Examples include hitting, biting, kicking, hair pulling, screaming, etc.

63 Glencoe Street, Unit 308

Nepean, Ontario, K2H 8S5

613-558-6338

admin@palstherapyclinic.com

Quick Links

FAQ

Privacy Policy

bottom of page