Post-Secondary Student ADHD Assessment

Patient Information

Patient Name(Required)

First Last

Post Secondary School(Required)

School Name

Patient Email(Required)

Patient Phone Number(Required)

Patient Street Address(Required)

Street Address Address Line 2 City Province Postal Code

Patient Date of Birth(Required)

Billing Details

Billing information same as Patient

Name(Required)

First Last

Email(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City Province Postal Code

Payment

Complete your payment of $200 CAD to get started.

Paying with PayPal

Using PayPal, you can pay with a credit card or a debit card. You do not need to have a PayPal account to make payment. If you already have a PayPal account you can also pay by the bank account linked to your PayPal account or with your PayPal balance.

Email

This field is for validation purposes and should be left unchanged.