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PROFESSIONAL REFERRAL
Please complete the following information below if you are acting on behalf of a child in a Professional capacity to renew an existing
contract.
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NAME OF CHILD: *
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DATE OF BIRTH *
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MM
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DD
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YYYY
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THERAPEUTIC PROGRAMS: *
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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
Play
Therapy
Counselling
Girls
Talk
Adoption
Services
Marschak (Attachment Assessment)
Sexual
Education Program
Sibling
Visits/ Retreats
Anger
Management
Bullying
Prevention
Trauma Assessment / Debriefing
Behavioural Assessment
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SESSIONS: *
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6
8
12
24
Please Choose the number of sessions required.
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FREQUENCY OF SESSIONS: *
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Weekly
Bi-Weekly (every 2 weeks)
2 times per
week
Monthly
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THERAPIST: *
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Please choose the therapist the child/youth is currently working with.
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NAME OF ADVOCATE: *
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AFFILIATED AGENCY: *
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RELATION TO THE CHILD / APPLICANT: *
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PHONE NUMBER: *
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EMAIL CONTACT: *
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OPR CASE MANAGER:
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REQUEST FOR CONTINUING SERVICES:
Please complete section below including any new information or changes with the child, you feel is important for the therapist to address.
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SUMMARY / TREATMENT OBJECTIVES: *
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BILLING OPTIONS: *
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Bill
Directly
Cost
Share
Other
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BILLING DETAILS / INSTRUCTIONS:
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UPLOAD CASE FILE
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Please attach any new documents, reports or files you feel may assist our therapists.
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AUTHORIZATION: *
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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.
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SIGN & DATE:
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Please sign and date ONLY if you are required to print off form and fax or mail in referral.
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Image Verification
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