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Internal – General Information Form (old)
Moshe Gotfryd
2018-12-13T10:19:52-05:00
General Information Form
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Primary Email Address - (This is the email address we will use for all Maxi Mind communications.)
*
This email address should match the primary email on all your Maxi Mind forms
Parent's Information
Mother's Name
First
Last
Mother's Email
Father's Name
First
Last
Father's Email
Home Number
Mother's Cell
Father's Cell
Address
*
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Where did you hear about Maxi Mind?
*
Please Select One
Internet Search
Google Ad
Referral
Facebook
Other
Please Specify
*
Insurance
Do you have health insurance over and above OHIP?
*
Yes
No
Child's Information
Child's Name
*
First
Last
Child's Date of Birth
*
Month
Day
Year
School Attending
*
Grade
*
Please Select One
Kindergarten
JK
SK
Pre 1A
1
2
3
4
5
6
7
8
9
10
11
12
Other
Not Applicable
Name of pediatrician/Family Dr.
*
First
Last
Please tell us about your child.
The more information you provide, the more we will be able to tell you if and how our program can help your child.
Describe any difficulties your child may be having at school.
*
Describe any difficulties your child is having at home or socially.
*
Has your child been diagnosed with any medical or psychological conditions or learning disorders?
No Diagnosis
ADHD
ASD (Autism)
LD
Dyslexia
MID
ODD (Oppositional Defiance Disorder)
Anaphylactic Allergy
Other
Please specify.
*
Does your child take medication for any of the above conditions?
*
Yes
No
Please specify the medications and dosage levels.
*
What are your hopes and expectations from the Maxi Mind program?
*
Additional notes or comments
*
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