BRANCHING OUT HOME

REQUEST FOR SERVICE- BRANCHING OUT

Enhanced Therapeutic Programing that is committed to nurturing a continual commitment of growth for children, youth and their families through treatment and support.

Please complete the following information below if you are requesting services on behalf of a child and would like Branching Out to initiate the referral process.
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 
 Play Therapy 
 Counselling 
 Family Support Worker  
 GROUP (Specify Below) 
 Adoption Services 
 Marschak Assessment 
 Sexual Education Program 
 Sibling Visits/ Retreats 
 Anger Management Group 
 Trauma Assessment  
 Behavioural Assessment 
 Triple "C" Program 
 Grief and Loss Group 
SESSIONS: *
Please Choose the number of sessions required.
 6   8   12   24 
 Group Hours   FSW Hours Specified Below 
FREQUENCY OF SESSIONS: *
 Weekly 
 Bi-Weekly (every 2 weeks) 
 2 times per week 
 Monthly 
 T.B.D (To be determined) 
NAME OF CHILD: *

First
Last
DATE OF BIRTH *

MM 		/
DD 		/
YYYY

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: *

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### 		-
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CELL PHONE NUMBER:

### 		-
### 		-
####
EMAIL: (Family Email)
OPR CASE MANAGER:
Email *
NAME OF ADVOCATE: (Worker) *

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

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

### 		-
### 		-
####
EMAIL CONTACT: *

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.
INDIVIDUAL HISTORY:
(Medical, Behavioural, Emotional Challenges)
SUMMARY / TREATMENT OBJECTIVES: *
BILLING OPTIONS: *
 Bill Directly (Carpe Diem) 
 Cost Share 
 Other 
BILLING DETAILS / INSTRUCTIONS:
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