Registration Form

Please complete and submit to validate your name on our wait list.



Client's Information






Male/ManFemale/WomanTransMale/TransManTransFemale/TransWomanGender Neutral/Gender NonconformingSomething elseDecline to answer


MarriedSingleSeparatedDivorcedN/A


YesNo








YesNo






MotherFatherCaregiverOther


YesNo






MotherFatherCaregiverOther


YesNo






Family / FriendsSocial MediaDoctorOther

Type of service requested




PsychologyDiagnostic assessmentPsychotherapyPsychiatry (please attach the referral letter to this form to ensure your place on the wait-list)Behaviour analysisSpeech language therapyOther – please specify


Scheduling of appointments


ParentCaregiverOther




Parent's RAMQ information




Person responsible for billing







Pharmacy





In case of an Emergency





By clicking send I confirm the above information is true to the best of my knowledge. I acknowledge that I have requested services from Clinique Spectrum from my free will and was not solicited by Clinique Spectrum or its associates. I also acknowledge that my clinical information will be entered onto OSCAR, Clinique Spectrum’s secure EMR (Electronic Medical Record) and that my nominal information will be visible to the healthcare professionals working at Clinique Spectrum. The data stored about me is encrypted.

Prior to filling out our forms, please ensure that you have the consent of the individual for whom you are filling out the forms (in the case of a minor, or an adult with an incapacity). Please read our privacy policy to learn more about how your personal information is protected through our website and communications.

Please also read below for our cancellation policy and services that are not covered by the RAMQ.

Services not covered by the RAMQ

Services not covered by the RAMQ

Cancellation Policy

We require 24 hours’ notice for any cancellation of a scheduled appointment. Where possible, we will reschedule the appointment. Without a written notification of cancellation to info@cliniquespectrum.com, we will be obliged to charge the hourly fee for services.

See Code de déontologie des psychologues art. 54 no. 3 & Code de déontologie des médecins, art. 104 à 106.