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Reach Child and Youth Development Society
Reach Child and Youth Development Society
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Online Referral Form - New Item
OT Referral Form
Child Section
Child's First Name
*
Child's Middle Name
Child's Last Name
*
Preferred Phone to Contact
*
Preferred Email for Contact
Child's Address
eg: 5678 Maple Street
Child's City
Child's Postal Code
Child's Identified Gender
M
F
Specify your own value:
Has Indigenous Ancestry
Yes
No
Date of Birth
*
Is Child In Care
Yes
No
Date Service is Needed
Check box if need is urgent
Please List Other Services The Child is Receiving
School/Preschool/Childcare Setting
School/Preschool/Childcare setting contact info
Times/Days Attending Child Care
Primary Language spoken at home
None
English
Mandarin
Cantonese
French
Hindi
Japanese
Korean
Punjabi
Spanish
Other
Translator Required
If yes please click box
Translation Required
English
Mandarin
Cantonese
French
Hindi
Japanese
Korean
Punjabi
Spanish
No
Specify your own value:
Other Language Spoken at Home
English
Mandarin
Cantonese
French
Hindi
Japanese
Korean
Punjabi
Spanish
Specify your own value:
BC Care Card Number
List child's allergies
Are any of the allergies anaphylactic?
Yes
No
Immunizations Up to Date
If yes please check box
Medication
Child's Diagnosis (if applicable)
None
(CDBC)Complex Developmental Behaviour Condition
Acquired/traumatic brain injury
ADHD/ADD
Anxiety Disorder
Aspergers
At risk
Autism Spectrum Disorder
Cerebral Palsey
Developmental coordination Disorder (DCD)
Developmental Delay
Developmental Delay: Query
Down Syndrome
Dual Diagnosis(Mental health with developmental delay)
FASD (fetal alcohol spectrum disorder)
Fragile X
Gifted
Hearing impaired
HIV positive/AIDS
Learning Disabilities
Mental health concerns
MID (mild intellectual disability)
MID (Moderate Intellectual Delay)
NAS (Neonatal Abstinence Disorder)
New Immigrant
OCD (Obsessive Compulsive Disorder)
Oppositional Defiant Disorder (ODD)
Other
Other Syndrome
PDD-NOS
Physical Disabilities
Premature
Seizure Disorder
Speech Delay
Spina Bifida
Static Encephalopathy
Tourette Syndrome
Undiagnosed
Visual impairment/Blind
Referral Reason
*
Please include as much information as possible
Not Parent/Guardian Section:
Please check this box if the person filling out this referral is not the Parent/Guardian
Not Parent/Guardian: Parent/Guardian is aware and consents to this referral
Yes
No
Please click Yes if the Parent/Guardian is aware and consents to this referral. We need consent to continue with referral.
Not Parent/Guardian: Relationship
None
Family Physician
Paediatrician
Child Care
Teacher
Support Teacher
Consultant
Therapist
Public Health Nurse
Other
Please select your relationship to the child
Not Parent/Guardian: Contact Info
Please put your name and phone number here
Parent/Guardian 1 Section (click '+' to complete details)
Parent/Guardian 1:
Click the '+' to complete details
Parent/Guardian 1: First Name
Parent/Guardian 1: Last Name
Parent/Guardian 1: Relationship to Child
None
Father
Mother
Brother
Sister
Grandparent
Social Worker
Foster Parent
Other Family
Parent/Guardian 1: Address same as child's
If same click box, if different then please fill in address fields.
Parent/Guardian 1: Address
eg: 5678 Maple Street
Parent/Guardian 1: City
Parent/Guardian 1: Postal Code
Parent/Guardian 1: Phone
Parent/Guardian 1: Email
Parent/Guardian 2 Section (click '+' to complete details)
Parent/Guardian 2:
Parent/Guardian 2: First Name
Parent/Guardian 2: Last Name
Parent/Guardian 2: Relationship to Child
None
Father
Mother
Brother
Sister
Grandparent
Social Worker
Foster Parent
Other Family
Parent/Guardian 2: Address same as child's
If same click box, if different then please fill in address fields.
Parent/Guardian 2: Address
Parent/Guardian 2: City
Parent/Guardian 2: Postal Code
Parent/Guardian 2: Phone
Parent/Guardian 3 Section (click '+' to complete details)
Parent/Guardian 2: Email
Parent/Guardian 3:
Parent/Guardian 3: First Name
Parent/Guardian 3: Last Name
Parent/Guardian 3: Relationship to Child
None
Father
Mother
Brother
Sister
Grandparent
Social Worker
Foster Parent
Other Family
Parent/Guardian 3: Address same as child's
If same click box, if different then please fill in address fields.
Parent/Guardian 3: Address
eg: 5678 Maple Street
Parent/Guardian 3: City
Parent/Guardian 3: Postal Code
Parent/Guardian 3: Phone
Parent/Guardian 3: Email
OFFICE USE ONLY ------------------------------------------------------------------------------------------
Program
Please select
Administration
All Staff Training-Ignore
ASCD
ASCD Authorizations
BIs Page
Choices
DCX Program
DCX/IF
Devon Wise
EIBI Program
EIBI/IF
Group Respite
IDP
Just Jammin
Moses Taban
MT IF
New Hire
OT
OT IF
PBS Program
PC
PLC
Preschool North
Preschool South
PT
PT IF
RCS
Reach ABA BC
Reach ABA Centre
Reach ABA Home
Reach ABA OT
Reach ABA SLP
Respite Program
SCD
S-C-D Authorizations
SFS
SFS Authorizations
Sibshops
SLP
SLP IF
SSG
TEENSS
TIP
Zachariyah Markiw
Content Type
Attachments:
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