Contact Form

Please complete the form to start a complimentary 30 minute introductory consultation. All enquiries will receive a response from our Board Certified Behaviour Analyst (BCBA) as soon as possible.

Thank you for your interest but, at this time we are only accepting in person clients in the Langley/Fleetwood/Cloverdale area and virtual clients across the province.

admin@bcbrightstars.com

Langley, British Columbia

Parents Name

To the protect the privacy and confidentiality of your family, we are only requesting names for parents and no identifying information for the student.

First Name

Last Name

Child's Birth Month and Year

Child's Age

Postal Code

Please describe some of your child’s strengths.

Please describe some of your child’s challenges.

Does your child require support with sleeping, feeding or toileting, please describe.

Are you open to parent coaching?

Yes

No

Is your child in any activities?

Preschool, swimming, music lessons, daycare, etc.

When is your child available for intervention?

Please provide specific days and time frames.

Email

Phone

(###)

###

####

What would be the best time of day to call for an initial consult?

Is there anything else you would like us to know about your child?