HEAR THE CHILD REPORTING INTAKE FORM

I confirm that, to the best of my knowledge, the information I have provided above is true and accurate. As such, I accept full responsibility for any delays, denial of service, or cancellation of service that may occur should this information be incorrect, misleading, or untrue. I agree that a copy of this intake form will be automatically sent by e-mail to myself and my legal counsel (if applicable), and authorize such disclosure. I confirm that I have read and agree to the Technology Terms of Use & Consent, the Privacy Policy, and the website Terms of Use, and consent to Leanne Toews or an authorized representative contacting me for the purposes of providing service(s) to myself or my family.