Book Now - Children



NOTE: All fields marked with a red * MUST be completed before you can submit. Give as much detail as you can.

Child Information

Preferred Name:

Date of Birth – Please complete (dd/mm/yyyy): *

Gender:

Gender Pronouns:

Gender Pronouns – Other:

Child is currently in grade: *







Parent or Legal Guardian Information

Parent or Guardian Marital status:*


Parent or Legal Guardian 1 – Contact Information


Parent or Legal Guardian 1 – Full Name:

Main Phone:

Email:

Mailing Address:

City:

Province:

Postal Code:


Parent or Legal Guardian 2 – Contact Information


Parent or Legal Guardian 2 – Full Name:

Main Phone:

Email:

Mailing Address:

City:

Province:

Postal Code:


Client Information

Please provide as much information as possible.


Request Details:

Assessment:

Calm Kids:

Reading Pilots:

ADHD Coaching:

What do you hope to achieve at CanLearn Society?

What are your main concerns? *


Do you have:

Concerns with Attention?

Concerns with Behaviour?

Concerns with Learning?

Concerns with Social/Emotional?

Concerns with Reading?

Has your child had a previous assessment? If yes, please provide the dates and details of the assessment: *



Has your child had a previous diagnosis? If yes, please provide details of any diagnosis made: *


CanLearn may transfer personal information to outside service providers that perform services on our behalf such as client relations management systems, or similar services. These service providers are located or store data in Canada. By providing personally identifiable information to us, you agree to the transfer of your personal information inside of Canada. More information about our privacy policies and practices can be accessed by contacting Laura Godfrey at 403-686-9300 ext. 126 or by clicking here.