Name *

First Name

Last Name

Phone *

(###)

###

####

Is your child in French immersion? *

Yes

No

Does your child speak English as a first language? *

Yes

No

Does your child speak other languages at home? *

Yes

No

Does this child receive learning assistance services at their school? *

Yes

No

Has your child had any educational assessments? *

Yes

No

Does your child have any allergies? *

Yes

No

Does your child have any other medical issues? *

Yes

No

Has your child's visual or hearing acuity been assessed? *

Click all that apply

Yes, visual acuity.

Yes, hearing acuity.

No

Does your child suffer anxiety in any circumstances? *

Yes

No

Does your child exhibit behavioural difficulties at home or at school? *

Yes

No

Does your child exhibit attentional difficulties at home or at school? *

Yes

No

Does your child take any medications or supplements? *

Yes

No

Does your child exhibit compulsive behaviours or tics? *

Yes

No

Where you referred to Reach? *

Yes

No