IMPORTANT: This form is for existing clients only

Contact Email*

Contact Phone Number*

Client Full Name*

Who is your main therapist at our clinic?*

What type of report or letter do you require?*

When do you need the report or letter by?*
(If you have a review meeting scheduled, please set this date to 2 weeks prior)

Who will be paying for this report or letter and which payment method are you using?*

Are you aware that reports and letters need to be paid in full prior to being provided to you?*

—Please choose an option—YesNo

Please visit our current pricing page (opens in a new tab or window) and enter the amount you expect to pay for your report or letter:*
(Noting that the usual report minimum charge is 3hrs of therapist time, or $581.97)

Please provide any other information you believe to be relevant (2500 character limit):

Please submit any supporting documentation you would like to provide :
(5MB maximum per file – PDF, JPG or DOCX preferred)

* = Required field

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