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**ROFILE OF CAFCO IN IMAGE SANDY HILL – APRIL/MAY 2014 ISSUE**

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Request for Services

Initial Appointment Request - Children

Service type *

Family Status *

-- Assessment --

-- Treatment --

-- Group Therapy--

Language *

Location *

Your name *

Client name (if different from above)

Client date of birth

Client school(if applicable)

Phone number with voicemail *

Email address *

Do you have insurance? *

Does your insurance cover: psychologist? *

Does your insurance cover: social worker? *

Does your insurance cover: speech-language pathologist? *

Referral Source *

Add Reason for referral/presenting problem *

Other requests or pertinent information?

By checking this box I hereby authorize the the Child, Adolescent, and Family Centre of Ottawa (CAFCO) to communicate with me via the means provided above regarding the services I am requesting. I also understand that CAFCO does NOT use email addresses or any other electronic addresses for commercial/promotional purposes as understood by Canada's Anti-Spam Legislaton (CASL).

Initial Appointment Request - Adolescents

Service type *

Family Status *

-- Assessment --

-- Treatment --

-- Group Therapy--

Language *

Location *

Your name *

Client name (if different from above)

Client date of birth

Client school(if applicable)

Phone number with voicemail *

Email address *

Do you have insurance? *

Does your insurance cover: psychologist? *

Does your insurance cover: social worker? *

Does your insurance cover: speech-language pathologist? *

Referral Source *

Add Reason for referral/presenting problem *

Other requests or pertinent information?

By checking this box I hereby authorize the the Child, Adolescent, and Family Centre of Ottawa (CAFCO) to communicate with me via the means provided above regarding the services I am requesting. I also understand that CAFCO does NOT use email addresses or any other electronic addresses for commercial/promotional purposes as understood by Canada's Anti-Spam Legislaton (CASL).

Initial Appointment Request - Adults

Service type *

-- Assessment --

-- Treatment --

-- Group Therapy--

Language *

Location *

Your name *

Client name (if different from above)

Client date of birth

Client school(if applicable)

Phone number with voicemail *

Email address *

Do you have insurance? *

Does your insurance cover: psychologist? *

Does your insurance cover: social worker? *

Does your insurance cover: speech-language pathologist? *

Referral Source *

Add Reason for referral/presenting problem *

Other requests or pertinent information?

By checking this box I hereby authorize the the Child, Adolescent, and Family Centre of Ottawa (CAFCO) to communicate with me via the means provided above regarding the services I am requesting. I also understand that CAFCO does NOT use email addresses or any other electronic addresses for commercial/promotional purposes as understood by Canada's Anti-Spam Legislaton (CASL).

Initial Appointment Request - Couples

Language of help needed *

Location *

Your name *

Your partner’s name *

Phone number with voicemail *

Email address *

Do you have insurance? *

Does your insurance cover: psychologist? *

Does your insurance cover: social worker? *

Does your insurance cover: speech-language pathologist? *

Referral Source *

Add Reason for referral/presenting problem *

Other requests or pertinent information?

By checking this box I hereby authorize the the Child, Adolescent, and Family Centre of Ottawa (CAFCO) to communicate with me via the means provided above regarding the services I am requesting. I also understand that CAFCO does NOT use email addresses or any other electronic addresses for commercial/promotional purposes as understood by Canada's Anti-Spam Legislaton (CASL).

Due to the COVID-19 pandemic, we are currently accepting new clients via telehealth (secure video conferencing) and psychoeducational and neuropsychological assessments only. Please submit your request online under “Request For Services.”

Unfortunately, our waiting list for face to face services is currently closed. We apologize for any inconvenience and appreciate your cooperation.

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