Children & Youth Services Referral Form

Please select your language.

Please select the program you would like to make a referral to:

Early Intervention Therapy ProgramVancouver Supported Child Development ProgramBurnaby Supported Child Development ProgramCommunity Brain Injury Program for Children & YouthKey Worker Support Services

If you need more information about our programs, please click on the link to our website

About Us

Please note, we provide rehabilitation services for children and youth under 19 who have been diagnosed with an Acquired Brain Injury post-birth from a one-time illness or injury within the last year, reside in BC with the right to live permanently in Canada, and who do not have access to third-party funding (i.e. ICBC, Crime Victim Assistance, Private Insurance).

If you are looking for information for a child or youth who have sustained a concussion, please refer to our website for resource or information regarding concussion. Alternatively, you can also contact the program coordinators directly at (604) 451-5511 ext. 1470 or ext. 1279, or via email at Whitney.Macrae@bc-cfa.org or Dana.Seidel@bc-cfa.org to discuss resources and supports that may be available within your community.

About Us

The Early Intervention Therapy Program provides therapy services and serves children who:

are between birth to kindergarten-entry age
have their home address in Vancouver, Burnaby, North Vancouver, West Vancouver or Richmond
have a confirmed or suspected developmental delay or disability
require Occupational Therapy and/or Physiotherapy along with Speech Therapy or support from our community feeding team

About Us

The Key Worker Program provides service to children and youth who:

live in Burnaby
are under 19 years of age
have a probable or confirmed diagnosis of FASD or CDBC
are facing challenges resulting in family stress or difficulties at school

About Us

The Supported Child Development Program assists families of children birth to 19 that are living or attending child care in Burnaby or Vancouver and require additional support to attend or access child care. Please complete the following form with as much detail as possible in order for us to serve you best.

Who is completing the referral?

Referrer Information

Referrer First Name

Referrer Last Name

Referrer Phone Number

Referrer Email

Referrer Fax Number

If child is currently in hospital, please provide an estimated discharge date in the section below

What's the reason for the referral?

What's the referring agency/organization?

What's the referring agency/organization address?

The parent/guardian is aware of and has provided consent for me to make this referral on their behalf

Consent is required. The form will not be submitted if you have not seleted 'yes'.

Please Note

This referral is considered incomplete until all supporting documentation has been received. Please attach any relevant medical documents in the section below or by fax to 604-451-5651.

Child Information

First Name

Last Name

MSP Personal Health Number

Date of Birth

Format (DD/MM/YYYY)

Gender

If you selected 'Other' please fill this in

Does the child have a diagnosis?

Child Diagnosis

Other Diagnosis Information (if applicable)

Please provide any relevant medical background history & information:

Is the child a current or former client at the BC Centre for Ability?

Guardian Information

Guardian 1 First Name

Guardian 1 Last Name

Guardian 1 Home Phone

Guardian 1 Mobile

Guardian 1 Email

Guardian 2 First Name

Guardian 2 Last Name

Guardian 2 Home Phone

Guardian 2 Mobile

Guardian 2 Email

Who is the legal guardian?

If you selected 'Other' please fill this in

Household Street Address

City

Postal Code

What is the preferred method of initial contact?

Does the family require an interpreter?

For which language?

If you selected 'Other' please fill this in

Referral Information

Is the child currently attending a Child Care Program?

Please provide the child care name & city it's located in:

What services are the family interested in?

PreschoolDaycareOut of School Care

What is the reason for this referral?

Have you made a referral to another BCCFA Program?

Early Intervention Therapy ProgramKey Worker ProgramCommunity Brain Injury Program for Child and Youth

Referral Information

Admission Date

Anticipated Discharge Date

Primary Community Physician

Recommended Service and Intensity

What is the reason for this referral?

Have you made a referral to another BCCFA Program?

Early Intervention Therapy ProgramKey Worker ProgramSupported Child Development Program

Referral Information

Does the child/youth have a confirmed diagnosis of FASD?

Does the child/youth have a confirmed diagnosis of any other neurodevelopmental condition?

If yes, please specify:

School/childcare name the child/youth attends (if applicable)

What is the reason for this referral?

Have you made a referral to another BCCFA Program?

Early Intervention Therapy ProgramCommunity Brain Injury Program for Children and YouthSupported Child Development Program

Supporting Documentation

Please attach any supporting documents (i.e. medical reports, school reports, etc.) regarding this referral in the sections below. Alternatively, you can send these documents via fax to 604-451-5651. Thank you.

How many supporting documents would you like to include?

Document 1

Document 2

Document 3