Early intervention services request

Early intervention services request form

Early intervention services are available from birth to school entry for families residing in the Maple Ridge/Pitt Meadows area

Please Note:

  • Incomplete forms will be returned to sender
  • Referrals for speech therapy only may receive services through the Fraser Health Authority or RMCDC.


Child's Name (required)

D.O.B

Sex
FemaleMale

Personal Health #

Address

Postal Code

Parent

Email (Required)

Home Phone

Alternate Phone

Work Phone

Guardian Name

Guardian Phone

Social Worker Name

Social Worker Phone

Physician Child Sees Most Frequently

Physician Phone

Other Agencies/Professionals/Physicians Involved

Diagnosis (if applicable)

Primary Concern(s)

Type of Service Requested (Check applicable concerns):

Occupational Theraphy: dressingtoiletingfeedingplay/fine motor skills

Physiotherapy: early movement/positioningupright mobilitygross motor skills

Speech/Language Therapy: speech/clarityunderstanding/use of wordsstutteringvoice


The next fields must be field by the person requesting the service

Name (required)

Agency (required)

Address (required)

Phone Number (required)

I have discussed this request for service with the above mentioned parent/guardian of the child.



Revised February 30, 2009

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Office hours: Monday 9:00 to 4:30, Tuesday-Thursday and 8:00 to 4:30 and Friday 8:00-3:30

  • 22610 Dewdney Trunk Road
  • Maple Ridge, BC V2X 3J9

There is no parking on Dewdney Trunk Road. Parking and RMCDC entrance are at the rear of the building which is accessed from the lane at the back.

  • Phone: 604.463.0881

  • Fax: 604.463.0026

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