BRANCHING OUT HOME

AGENCY / PROFESSIONAL REFERRAL FORM

PROFESSIONAL REFERRAL

Please complete the following information below if you are acting on behalf of a child in a Professional capacity to request a Referral for Services.
NAME OF CHILD: *

First
Last
DATE OF BIRTH *

MM 		/
DD 		/
YYYY
THERAPEUTIC PROGRAMS: *
Choose one of the following options.
If you are not certain the type of support you or your child may require, please choose the Therapy option. Our therapist can assess which service would be best suited for your needs.
 Therapy 
 Sexual Education Program 
 Play Therapy 
 Counselling 
 Girls Talk 
 Sibling Visits/ Retreats 
 Adoption Services 
 Bullying Prevention 
 Parent Support 
 Anger Management 
 Marschak
     (Relationship Assessment)
 Trauma Assessment /
     Debriefing 
 Psychosocial Behavioural
     Assessment 
 Special Request (see notes) 
SESSIONS: *
 6 
 8 
 12 
 24 
 Group Sessions 
Please Choose the number of sessions required.
FREQUENCY OF SESSIONS: *
 Weekly 
 Bi-Weekly (every 2 weeks) 
 2 times per week 
 Monthly 

FAMILY DETAILS:

Please include name and current address of parent(s) or Legal Guardian.
NAME OF PARENT /LEGAL GUARDIAN / CARE GIVER:

Prefix
First
Last
Suffix
CURRENT ADDRESS: *

Street Address

Address Line 2

City
State / Province / Region

Postal / Zip Code
Country
HOME PHONE NUMBER: *

### 		-
### 		-
####
CELL PHONE NUMBER:

### 		-
### 		-
####
EMAIL:
Confirm EMAIL:

ADVOCATE INFORMATION:

Infromation on the professional making the request for services. Please include any information regarding the child/applicant's association with any organization or agency.
NAME OF ADVOCATE:

First
Last
RELATION TO THE CHILD / APPLICANT: *
PHONE NUMBER: *

### 		-
### 		-
####
FAX NUMBER: *

### 		-
### 		-
####
EMAIL CONTACT: *
AFFILIATED AGENCY: *
AGENCY CONTACT: (only if different from advocate)

First
Last
RELATION TO THE CHILD / APPLICANT: (only if different from advocate)
PHONE / FAX NUMBER:

SUMMARY - REQUEST FOR SERVICES

Please complete section below including any information you feel may assist us in processing you application and matching your needs to the expertise of our facilitators and therapists.
DIAGNOSIS:
SUMMARY / TREATMENT OBJECTIVES: *
OPR CASE MANAGER:
UPLOAD CASE FILE
Please attach any documents you feel may assist our therapists.
BILLING OPTIONS: *
 Bill Directly 
 Cost Share 
 Other 
BILLING DETAILS / INSTRUCTIONS:
AUTHORIZATION: *
  Yes, as parent, legal guardian, caregiver, I authorize the above named child/applicant to participate in Branching Out programs. By electronically submitting this application I am authorizing and agree to the terms below. 
My child will be supervised during all activities.
Sessions will be taped for the purpose of supervision and training only.
I give permission for Branching Out staff to administer emergency medical treatment or involve professional medical staff if necessary.
I understand that if I do not attend a session without 24hours notice, I will be charged for the entire session.
I understand should the decision be made to end therapy, I will agree to (2) additional closure session in the best interest of the applicant.
SIGN & DATE:
Please sign and date ONLY if you are required to print off form and fax or mail in referral.
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