Intake Form for Adults Ages 18 and Up

Intake Form for Adults Ages 18 yrs+
Please Note:

Our online forms use SSL encryption to maintain secure transmission of medical information.

Forms MUST submitted online.
For patients 18 to 21 years it is strongly encouraged
that parent(s) attend the initial appointment with MD.
Welcome to Possibilities. We are a Clinical Team of experts in Learning Disabilities and Giftedness and ADD/ADHD.

We want to get to know you and your family! That way we can start figuring out the assessment and treatment services you need.

Let’s get started!
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Yes. I have 30 minutes to complete the survey right now. No. I’ll have to do this later but I understand that the clinic can’t book the appointment until this survey is complete.

Experts at Possibilities acknowledge the complexity of neurodevelopmental disorders. That means:
- Most of our assessments involve a Clinical Team of both physicians and allied health professionals like Psychologists, Social Workers, and Occupational Therapists
- There is a cost to our Clinical Team Assessments since allied health professionals are not covered by the Ontario Health Insurance Plan (OHIP). Assessment costs vary from $1750 to $4500 depending on the service.
- Private therapies are available at Possibilities with a team of Psychologists, Social Workers, Occupational Therapists, and Executive Functioning Therapists. Rates range from approximately $130 to $255 per session. Many of these fees are covered by private insurance plans; please check with your insurer for potential coverage.
- Only the medical portion of our Clinical Team assessments involving the physician is covered by OHIP when a valid health card is presented.
- If the assessment you need involves one of our physicians, we require a referral from your Family Doctor.
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Yes. I am eager to get started and understand the costs involved in assessments and therapies. No, I do not wish to proceed with Possibilities at this time. I will go back to my Family Physician and request a referral to a community-based service where both physician and allied healthcare costs are covered.

Reasons for Referral
Have you been previously diagnosed with any of the following? Check all that apply. *

ADD/ADHD Learning Disabilities I have not been previously diagnosed
If Yes to any of the above, please list assessment(s) and date(s) of assessment(s):
What services are you considering? Check all that apply. *

Therapy (e.g. coaching, psychotherapy, CBT, OT, SLP, group) Receiving a Comprehensive Assessment for ADHD Psychoeducational Testing/Neuropsychological Assessment
What are your areas of concern? Check all that apply. *

ADD/ADHD Learning Disabilities

What is the main purpose of this assessment? *
What concerns do you have that you would like us to help with? (minimum 50 words)? *

0/500
Have there been any psychotherapy treatments? If so describe. *
If there are any CURRENT medication treatments, list medications, doses, and responses. *
If there were any PAST medication treatments, list medications, doses, and responses. *

You don't have time to complete the form right now, but that's okay.

Just come back when you have time and complete our Intake Form.

We look forward to working with you.

Thank you for taking the time to begin our Intake form.

You have decided to go back to your Family Doctor.

We wish you all the best on your journey.
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Patient Information