Parent Consent Form

If you do not wish to use our online form please download our pdf form for submission by fax or email (scanned copy).

Child Information

MSP Personal Health Number

Child's First Name(Required)

Child's Last Name(Required)

Date of Birth(Required)

DD dash MM dash YYYY

Child's Gender(Required)

Male

Female

Assigned gender at birth

Please specify

Name of Person(s) Child Resides with (First and Last)(Required)

Person filling out this form, relationship to the child(Required)

Both Parents

Single Parent

Grandparent(s)

Foster Parent(s)

Other Caregiver(s)

Name of siblings child resides with

Home Address(Required)

City(Required)

Postal Code(Required)

Email Address(Required)

Home Phone Number(Required)

Cell Phone Number

Are you the legal guardian for this child?(Required)

Yes

The legal guardian for this child is(Required)

Both Parents

Mother Only

Father Only

Maternal Grandparent(s)

Paternal Grandparent(s)

MCFD Social Worker

Other

Social Worker Name(Required)

Relationship to this child(Required)

If applicable, please provide a copy of any legal custody document regarding this child

Drop files here or

Max. file size: 200 MB.

Alternate Contact Information

Name of Alternate Parent or Guardian (First and Last)

Alternate Parent is

Mother

Father

MCFD SW

Foster Parent

Other

Cultural Information

Do you wish to self-identify your child as

First Nations / Aboriginal Ancestry

Yes

Metis

Yes

Other Self-identified culture

Yes

Please describe other culture:

Additional Information

Daycare/Preschool (if applicable)

Daycare Phone Number

Primary Language spoken at home

English

Other

Are you comfortable communicating in English?

Spoken English?

Yes

Written English?

Yes

Would an interpreter be helpful?

Yes

Not required

Birth Information and Medical History

Pregnancy and birth description

Healthy, with no complications

Complications

Please provide medical and health details

Delivery

Vaginal

Caesarean

Born at (specify in weeks)

Birth Weight

Weight in

Pounds

Kilograms

Was there any known fetal exposure to alcohol?

Yes

Was there any known fetal exposure to prescription drugs?

Yes

Please provide details

Was there any known fetal exposure to non-prescription drugs?

Yes

Please provide details

MEDICAL HISTORY

Does your child use medication?(Required)

Yes

Medication details

Has your child been seen by a specialist?(Required)

Yes

Specialist details

Does your child have a diagnosis?(Required)

Yes

Diagnosis details

Has your child been hospitalized at any time?(Required)

Yes

Hospitalization details

Does your child have allergies?(Required)

Yes

Allergy details

Additional Details

HEARING

Was hearing tested at birth?

Yes

Were any of the following recommended?

Follow-up and/or monitoring

A hearing device

History of ear infections?

Yes

Ear Infection Details

VISION

Has vision been tested?

Yes

Was the following recommended?

Follow-up and/or monitoring

Development Information

Parent/Guardian Priorities – Reason for Referral

What are the most important issues that you hope will be addressed with your child?

FEEDING

Is feeding a concern (picky eater, coughing or choking during meals)?

Yes

Please provide details of concerns.

We work in collaboration with the Feeding and Swallowing Team at Kelowna General Hospital (KGH).

Have you, or will you receive support from the KGH Feeding and Swallowing Team?

Yes

If yes, do you consent to Starbright sharing information with the KGH Feeding and Swallowing Team?

Yes

ACTIVITIES OF DAILY LIVING

Please check if you have concerns with any of the following activities

Dressing

Toileting

Hygiene

Sleep

If yes, please provide details

COMMUNICATION

Are there concerns with communication?

Yes

Please provide details

How many words does your child use right now?

Does your child combine words?

Not Yet

Yes

If your child combines words, please give some examples.

Do you find your child difficult to understand?

Yes

Do others find your child difficult to understand?

Yes

Is your child able to follow simple/familiar instructions?

Not Yet

Yes

Is your child able to follow complex/multiple instructions?

E.g. “Take the toy to your room and bring me the book.”

Not Yet

Yes

To prevent duplication of services, we work in partnership with the Speech and Language Department at Interior Health.

Do you consent to Starbright sharing information with the Speech and Language Department at Interior Health

Yes

LARGE MUSCLE MOVEMENT

Do you have concerns with your child achieving skills as rolling, crawling, sitting and/or walking?

Yes

Please describe

SMALL MUSCLE MOVEMENT (FINGERS, HANDS)

Do you have concerns around fine motor development?

Yes

Please describe

INTERACTION WITH PEOPLE AND ENVIRONMENT

Do you have concerns with how your child transitions from one activity or situation to another?

Not applicable

I am not sure

Yes

Please provide details

Does it sometimes take longer than you might expect for your child to settle when upset?

Yes

Please provide details

Do you have concerns with how your child responds to: touch, sound, movement?

Yes

Please provide details

Has your child experienced an episode or period of high stress?

Yes

Please provide details

When other children are around, my child typically:

shows an interest and interacts

plays beside them but not with them

tends to play on own

Other Services

Does your child receive other treatments for your concerns (e.g. private speech, private physiotherapy, naturopathy, massage, chiropractor, acupuncture, ASD services, etc.)?(Required)

Yes

Please provide details

Consent for Service

I understand that I will be contacted by someone from Starbright Children’s Development Centre by email, and/or phone.

I understand that Starbright’s services are provided at our Centre, at home or via tele-health, based on your child or family circumstances.

I understand that if Starbright’s sessions are being conducted by tele-health, this includes treatment using interactive audio, video, or data communications, and that:

I am responsible for providing the necessary computer, telecommunications equipment, and internet access for the tele-health sessions,
I am responsible for the information security on my computer, and
I am responsible for arranging a place/space with sufficient lighting and privacy for my tele-health sessions.

Please check off the following:

If you are not self-referring, do we have your permission to contact the referral source?(Required)

Yes

Do you agree to have practicum students observe and/or participate in therapy?(Required)

Yes

Do you agree that Starbright Childrens Development Centre may use audio/visual technology (for the purpose of recording therapy, assessment and progress only)?(Required)

Yes

Would you like to receive Centre information such as newsletters and surveys?(Required)

Yes

Would you like to receive parent workshop offerings from Starbright?(Required)

Yes

Are there any other contacts we can call in case of an emergency?(Required)

Yes

Emergency Contact #1

Contact Name

Home Phone Number

Cell Phone Number

Relationship to Child

Emergency Contact #2

Contact Name

Home Phone Number

Cell Phone Number

Relationship to Child

To prevent duplication of services, we work in partnership with the Speech and Language Department at Interior Health and the Family Connection centre (FCC). We review all new referrals on a regular basis and divide them between the three agencies so that your child receives the best service available.

This field is hidden when viewing the form

Do you consent to Starbright sharing referral information with the Speech and Language Department at Interior Health and with the Family Connection Centre (FCC)

Yes

Starbright Children’s Development Centre Consent to Obtain/Release Information

Please complete information below for all providers for which you give consent.

To provide safe and effective services for your child, Starbright staff may need to request information from, and share information with, your child’s other service providers. All information is treated as strictly confidential. A copy of this consent will be sent to all persons/agencies when information is requested from them. Starbright reports will be sent to the parent(s) and/or guardian(s).

Family Physician

I give my consent to:

Release

Obtain

Family Physician Name(Required)

Phone Number(Required)

Pediatrician

I give my consent to:

Release

Obtain

Pediatrician Name(Required)

Phone Number(Required)

Preschool/Daycare

I give my consent to:

Release

Obtain

Preschool/Daycare Name(Required)

Phone Number(Required)

Ministry of Children and Family Development - MCFD

I give my consent to:

Release

Obtain

Name of Social Worker(Required)

Public Health Nurse (IH)

I give my consent to:

Release

Obtain

Public Health Nurse Name(Required)

Kelowna General Hospital

I give my consent to:

Release

Obtain

Children and Youth with Special Needs

I give my consent to:

Release

Obtain

Interior Health Children's Assessment Network (IHCAN)

I give my consent to:

Release

Obtain

Okanagan Ability Centre

I give my consent to:

Release

Obtain

BC Children's Hospital

I give my consent to:

Release

Obtain

Dept (Check all that apply)

Neurology

Orthopedics

Cardiology

Oncology

Genetics

Epilepsy

Muscle Diseases

Bio Chem Disease

Complex Feeding Team

Feeding Swallowing Team

Sunnyhill Health Clinic

I give my consent to:

Release

Obtain

Dept (Check all that apply)

Assessment

Visual Impairment Team

Assistive Technology

Positioning and Mobility Team

Hearing Loss Team

Complex Developmental Behaviour Conditions

Other Service (Optional)

I give my consent to:

Release

Obtain

Other Service Information

I authorize Starbright Children's Development Centre to obtain and/or release information regarding my child

Child's Name

DOB

DD slash MM slash YYYY

from the persons/agencies listed above.

I understand and agree that this consent for service and this consent to obtain/release information, will continue to remain in effect until all services provided to my child or children by Starbright Children’s Development Centre have ended, or until I have changed this consent. I understand I may request to have my Consent Form updated as information changes.

Signature

Printed Name of Legal Guardian

Relationship to the Child

Date

DD dash MM dash YYYY