Children & Youth Services Referral Form

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

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 or to discuss resources and supports that may be available within your community.

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

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

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. 

Referrer Information

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

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

Format (DD/MM/YYYY)

Guardian Information

Referral Information

Referral Information

Referral Information

Referral Information

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.