Pediatric Outreach Therapy Program Agency Referral

Thank you for taking the time to complete a referral to the Pediatric Outreach Therapy Program (POTP). This is a new program designed to support children and families to access Early Intervention Therapy services (ages 0-5) in underserved communities across BC.

The information provided on this form will help us begin to understand the therapy needs of communities across the province. Following receipt of this referral form, our Program Coordinator will be in touch to schedule a virtual meeting to discuss your organization’s needs in more detail.

Referring Agency & Contact Information

Name of person completing this form

Title

What is your relationship with the referring agency

Phone

Phone extension (if applicable)

Name of referring agency

Are you the primary contact for referring agency?

Referring agency primary contact name

Referring agency primary contact email

Referring agency primary contact phone

Primary contact extension (if applicable)

Referring Agency Service Needs

Tell us a bit about your community, and how you would like us to help

Please specify the number of children that your team is currently not able to support in each discipline. Please elaborate in the notes section if there is a specific condition or group you need support with.

Do you require Occupational Therapy (OT) services?

Approximately how many clients are requiring OT service?

Do you require Physiotherapy (PT) services?

Approximately how many clients are requiring PT service?

Do you require Speech Language Pathology (SLP) services?

Approximately how many clients are requiring SLP service?

Do you require Behavioural services?

Approximately how many clients are requiring Behavioural service?

Please indicate other relevant information regarding your service needs