PEDIC

If you wish to make an appointment with a psychologist/reading specialist, simply complete the form below.
1. Are you requesting an in-person session or a virtual online session?

Virtual online sessionIn-person session
2. How did you find out about our service?

Ministry of EducationChildren's AuthorityTeacherSchool Guidance OfficerInformation Booklet/BrochureFriend/FamilyInternet/WebsiteDoctorOther
3. Reason for requesting services:
4. Client Type:

IndividualClassroomSchool
*If you wish to request services for a classroom or school, please proceed to questions 19-22
INDIVIDUAL:
5. Name of Client:

First NameLast Name
6. Returning or New Client:

New ClientReturning Client
7. Client Sex:

MaleFemale
8. Client's Residential Address:
9. Date of Birth:

MonthDayYear
10. Is Client under 18 years old?

YesNo
*If ‘No’, proceed to question 14
11. School attended by Client:
12. Name(s) of Parent/Legal Guardian(s):

First NameLast Name
13. Relationship of Legal Guardian(s) to Client:
14. Contact # of Client/Legal Guardian(s):
Please enter a valid phone number.
15. Email Address of Client/Legal Guardian(s):
16. Name(s) of In-Case-of-Emergency (I.C.E) Contact Person(s):

First NameLast Name
17. Relationship of I.C.E Contact to Client:
18. Contact # of I.C.E Contact:
Please enter a valid phone number.
CLASSROOM/SCHOOL
19. Name of School:
20. School's Address:
21. School's Telephone Number:
Please enter a valid phone number.
22. School's Email Address:
Please verify that you are human*
Should be Empty: