Child/Adolescent Full Name

First Name

Last Name

Child/Adolescent Date of Birth

YYYY

Parent/Guardian Full Name, and Relationship to Child/Adolescent

Parent/Guardian Phone Number

Parent/Guardian Email Address

Availability for Appointments

Please check ALL options that could potentially suit for regular appointments.

Tuesdays (7:00am-9:00am)

Tuesdays (9:00am-1:30pm)

Wednesdays (7:00am-9:00am)

Wednesdays (9:00am-1:30pm)

Friday (7:00am-9:00am)

Fridays (9:00am-1:30pm)

Availability for Appointments - Additional Information

If relevant, please add any additional information, requests or preferences around your availability for appointments here.

Message

Please include information about the difficulties or challenges the child or adolescent is experiencing, including any confirmed or suspected diagnoses they may have. Please note: Talia DOES provide therapy for people with ADHD and ASD, but does not offer ADHD/ASD assessment or diagnosis services. Talia does not provide therapy for Borderline Personality Disorder (or other Personality Disorders), nor for Eating Disorders.

Referral and Funding Information

Please select the most appropriate option.

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