151 Pine Valley Drive
London, Ontario N6J 4M2
519-435-6499
866-504-3115 (Fax)
Teenagers 13 - 17 years old
IF YOUR TEENAGER IS BEING REFERRED FOR AN AUTISM ASSESSMENT, I STRONGLY RECOMMEND THAT IT BE DONE IN-PERSON (at my office in London).
Click on the PDF icon to download the Intake Questionnaire to your computer. There are two parts to this questionnaire: one for parents to complete and one for the teenager to complete by themselves. It is best if you complete your part, then have them come in and complete their part right away. IF THEY CANNOT/DO NOT, then be sure to save the partially completed pdf file so that they can complete it later.
Once it is complete, click on the SUBMIT button. The PDF form will be submitted via your default email program. If you use a web-based e-mail (i.e. Gmail, Hotmail, Yahoo, etc.), you will need to go into your e-mail and send it to me (as an attachment) at drtemplemanintake@gmail.com.
YOU CAN ONLY SUBMIT FULLY COMPLETED QUESTIONNAIRES!
After you have submitted it, you will receive a confirmation email from my office that I have received it. If you do not receive this confirmation email, I have not received it yet. Please note that this email is NOT MONITORED by humans and is ONLY used to receive intake files. If you are sending any other supporting documentation, please be sure to put your teenager's first and last name (as it appears on their health card) in the subject heading of the email.