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 (required)

Sex (required)
FemaleMale

Personal Health #

Aboriginal Heritage (required)
YesNo

Language(s) spoken

Interpreter Required (required)
YesNo

Child resides with

Specify (If Other)

Legal Guardian is

Specify (If Other)

#1 Parent/Guardian Name:

Email

Address

Postal Code

Parent/Guardian Home Phone

Cell Phone

Work Phone

#2 Parent/Guardian Name:

Email

Address

Postal Code

Parent/Guardian Home Phone

Cell Phone

Work Phone

Physicians/Professionals/ Agencies Involved

Diagnosis (if applicable)

Primary Concern(s)

Type of Service Requested (Check applicable concerns):

Occupational Therapy: dressingtoiletingfeedingplay/fine motor skills

Physiotherapy: early movement/positioningupright mobilitygross motor skills

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

Complex Feeding Team (OT/SLP): failure to thrivesafety riskstube feedingbottle transitions


The next fields must be filed 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.



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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

  • Unit 201 21755 Lougheed Highway
  • Maple Ridge, BC V2X 2S2

  • Phone: 604.463.0881

  • Fax: 604.463.0026

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