Name *

First Name

Last Name

Phone *

(###)

###

####

If this referral is being made by a professional on behalf of the parent/guardian or youth, please check one of the following: *

I have consent from the parent/guardian or individual to disclose verbal/written information, electronic correspondence, and formal reports addressed specifically to *Relanding Psychological Services.* If you are checking this box, please send proof of consent to: info@relandingpsychologicalservices.ca

I do not have consent from the parent/guardian or individual to disclose verbal/written information, electronic correspondence, and formal reports to Relanding Psychological Services. If you are checking this box, please note that we cannot provide an intake without consent and you will either have to 1) gain this consent from the parent/guardian or individual or 2) have the parent/guardian or individual contact us directly.

Not Applicable

Please indicate your preference for leaving voicemails on the number listed. *

Yes, you can leave a voicemail.

No, please do not leave a voicemail.

Is it okay to write back to this email? *

Yes

No