Playful Healing

Part 1:

Referral Agency(Required)

Date(Required)

Address(Required)

Street Address Address Line 2 City

Phone(Required)

Email(Required)

Referred by:(Required)

First Last

Part 2: PATIENT INFORMATION

Name(Required)

First Last

Date of Birth(Required)

Location of Residence(Required)

Kelowna

West Kelowna

Peachland

Lake Country

PART 3: Parent/Caregiver Information

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City

Email(Required)

Phone(Required)

Relationship to Child(Required)

PART 4: COMMENTS/REASON FOR REFERRAL(Required)

PART 5: TERMS OF AGREEMENT

To be completed by referral agency only.(Required)

The information presented in this referral is true and complete to the best of my knowledge

I have read and agreed to the privacy policy ( see below)

Childhood Connections may contact me or the referral family with regards to therapy services

I have express verbal/written permission from the child’s legal guardian to share this information with Childhood Connections and provided contracted agency

I have thoroughly read and understand the guidelines of Playful Healing referral program and agree this applicant meets the guidelines. I believe the family of this child has financial need and this service is essential to the child’s well-being

Consideration(Required)

First time applicants will receive priority on the waitlist

Returning applicants will be considered as funding permits

Unsuccessful applicants will be notified as quickly as possible

Guidelines(Required)

Child must be between the ages of 30 months and 12 years

Parent and or Caregiver maybe require to participate in sessions and are required participate in take session with contracted agency

Child must be a resident of the central Okanagan

The child’s family must face considerable economic barriers ($60,000)The child’s family must face considerable economic barriers ($60,000)

The funding will go directly towards paying for the therapy sessions

Only one application per family per calendar year

Preference is given to first time applicants

Continuous No Shows to sessions may terminate playful healing sessions

Parent/Guardian(Required)

The parent/guardian must give full verbal/written consent for the agency to submit an application on their behalf

Privacy/confidentiality policy(Required)

Childhood Connections respects your privacy. We never sell, trade or loan your information to any other organization. Information provided in this referral is being collected solely for the purpose of Playful Healing. The information will only be disclosed to Childhood Connections staff and contracted therapists to carry out the responsibilities of their job. Statistics are reported at the regional and provincial level, however, individuals are not personally identified in any way. By completing and submitting this application form you agree to have all collected information stored in our database system.

Other Programs – Please indicate if the referral family is interested in or you think would benefit from any of the additional services below

Circle of Security Parenting Course

Nobody’s Perfect Parenting Course

Nourish Families Program

Signature(Required)

Playful Healing Referral

Part 1:

Part 2: PATIENT INFORMATION

PART 3: Parent/Caregiver Information

PART 5: TERMS OF AGREEMENT