Referral Form - Kinsight

You must live in New Westminster or the Tri Cities* (Coquitlam, Port Coquitlam, Port Moody) or have a child attending a childcare program in one of these communities to be eligible to receive services.
*If you live in Anmore or Belcarra, or have a child attending a childcare program in either of these communities, please select Tri Cities below.

New Westminster or Tri Cities*

Please indicate which one of the following applies to you:*

Parent/Family Member
Community Services Provider

Relationship to Child*

Other:*

Other:

If you are a Community Services Provider, please check this box to indicate that you have spoken to the family and they have consented to this referral.

Please select the type of Community Services Provider/Organizationfrom the drop down list:*

Other*

Name of Referral source:*

First Last

Phone*

Do you identify this child as having Aboriginal heritage? (Status, Non-Status, First Nations, Inuit, Metis)*

Yes
No

All Infant Development Program and Supported Child Development Program referrals for children identified as having Aboriginal Heritage will be forwarded to Spirit of the Children Society.

Language Spoken in the home other than English:

Is an interpreter required?

Yes
No

What are you worried about regarding your child's development (include information on diagnosis, assessments, other referrals, other professionals involved)*

Please check all that apply (program descriptions below)*

Infant Development (Birth to 3 Years)
Occupational Therapy (Birth to 5 Years)
Physical Therapy (Birth to 5 Years)
Speech-Language Therapy (Birth to 5 Years)
Supported Child Development (Birth to 19 Years)
Key Worker Services (Birth to 19 Years)

Child's Name

First Last

Gender:*

Date of Birth (DD/MM/YYYY)*

Expected Date of Birth - If Premature (DD/MM/YYYY)

Parent Name*

First Last

Primary Contact Number*

Alternate Phone Number

Address*

Street Address City Province Postal Code

Email

Do you want to add contact information for a 2nd parent?*

Yes
No

Parent Name - 2

First Last

Address (if different)

Street Address City Province Postal Code

Primary Contact Number

Alternate Number

Email

Is the child in the care of the Ministry of Child and Family Development?*

Yes
No

Name of Legal Guardian

First Last

Primary Contact Number

Fax Number

Address

Street Address City Province Postal Code

Family Doctor

First Last

Contact Number

Specialist Name

First Last

Contact Number

Does the child attend Preschool, Daycare or School?*

Preschool/Daycare/School Name*

Contact Number