Ctfrc Referral - Children's Therapy & Family Resource Centre

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CTFRC Referral Form

Last Name

First Name

Middle Name

Also Known As

Date of Birth (MM/DD/YY)

Age at Referral

Gender (Male/Female)

Physician

Parent/Caregiver Name(s)

Relationship to Child

Address (street address)

City

Postal Code

Address (mailing address if different from above)

City

Postal Code

Home Phone Number

Work Phone Number

Cell Phone Number

Email Address

Legal Guardian Name(s) (if different from parent or caregiver)

Realationship to Child

Phone Number

Legal Guardian Address (street address)

City

Postal Code

Name of Preschool, Daycare, School, etc.

Grade

First Nations/Aborigional Ancestry (Y/N)

Band Name

Allergies (Y/N)

Details of Allergies

Special Precautions

Personal Health Number

Primary Language Spoken

Primary Language Written

Interpreter Required (Y/N)

Who can refer? Anyone (Parents, Physicians, Daycares, School, etc.) may refer to our centre (with legal guardian's consent.)

Referral Source: (if different from parent)

Name

Signature (electronic signature assumed)

Address

Postal Code

Phone Number

Relationship of Referral Source to Child

Referral Taken by:

In Person

By Phone

Is Family aware of Referral?

Yes

No

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Children's Therapy & Family Resource Centre

The Children’s Therapy & Family Resource Centre is located in Kamloops, B.C. The centre is a non-profit agency and has been owned and operated by the Thompson Nicola Family Resource Society since 1991. We are proud to be CARF accredited. Our centre is governed by a board of directors, consisting of both parents and community members, who are responsible for the agency’s overall operation.

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Children's Therapy & Family Resource Centre