Contact Form for Autism Center | Autism Therapy & Child Counselling Institute

Child's Age

Select the age range of your child.

0-2

2-5

5-9

9-12

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Child's Diagnoses

Select all applicable diagnoses.

ADHD

Autism

PDA

PANDA/PANS

Learning Disabilities

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Therapies Attended

Select all therapies your child has attended.

ABA

Miller Method

Floortime

Sunrise

PRT

Psychotherapy

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Is your child currently using medication?

Please indicate if your child is taking any medication.

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Location

I want to make an appointment at your_____ location

Vaughan

Oakville

Markham

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Insurance Type

Select your payment preference .

Insurance

OAP

Out of Pocket

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Email

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Child Name

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Parent name

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Phone/WhatsApp number:

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