Parent Consent Form (Head Shape)

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

Childs Resides with

Both Parents

Mother Only

Father Only

Maternal Grandparent(s)

Paternal Grandparent(s)

Foster Family

Caregiver(s)

Other

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

Hidden

Person filling out this form, relationship to the child

Both Parents

Single Parent

Grandparent(s)

Foster Parent(s)

Other Caregiver(s)

Home Address(Required)

City(Required)

Postal Code(Required)

Email Address(Required)

Home Phone Number(Required)

Cell Phone Number

Hidden

Are you the legal guardian for this child?

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.

Parent/Guardian Priorities – Reason for Referral

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

Cultural Information (Optional)

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:

Please describe any cultural or religious beliefs and values that we need to be aware of in providing services to your child:

Additional Information

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 description

Healthy, with no complications

Complications

Please provide medical and health details

Delivery

Vaginal

Caesarean

Gestational Age (specify in weeks)

Birth Weight (please indicate pounds or kilograms)

Was there any known fetal exposure to alcohol?

Yes

Hidden

Was there any known fetal exposure to prescription drugs?

Yes

Hidden

Please provide details

(Non) prescription drugs?

Yes

Please provide details

MEDICAL HISTORY

Does your child have ongoing health issues?

Yes

Please provide details below

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

Corrective lenses

Development Information

FEEDING

Currently breastfeeding

Yes

Is feeding a concern?

Yes

Please provide details of concerns

Hidden

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

Yes

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

Hidden

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

Yes

LARGE MUSCLE MOVEMENT (SITTING, CRAWLING, WALKING)

Are there concerns with large muscle movement?

Yes

How old was your child when s/he began to do each of the following below.
Note: If it did not happen yet just add "Not Yet".

Rolling

Sitting

Crawling

Walking

Notable concerns

SMALL MUSCLE MOVEMENT (FINGERS, HANDS)

Are there concerns with small muscle movement?

Yes

Is your child using their arms and hands to reach and grasp?

Not Yet

Yes

Do you have concerns?

Yes

Please describe

FAMILY HISTORY

Please provide relevant details on family history with regard to e.g. medical, physical, health, mental health, learning difficulties, vision, hearing, communication:

Other Services

Does your child receive other early intervention services (e.g. speech, physiotherapy, etc.) from other service providers?(Required)

Yes

Please provide details

Add the name of centre/s with some 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:

I understand that when this request for service is received, I will be contacted by someone at Starbright Children’s Development Centre.

I prefer to be contacted to schedule appointments by

Telephone

You may check more than one.

I prefer to receive written information and correspondence about my child by

Regular mail

You may check more than one.

If you choose the email option, please remember the following:

For our clients and their families: Please know that there is always a risk that email may be intercepted between the sender and the receiver. Starbright Children’s Development Centre does not use email for confidential information unless that mode of communication is specifically requested by the client/family. Email is not secure, nor is it confidential. If you continue to use email communication, it means that you accept this risk. If you feel that email communication is insufficiently secure for the confidential information you wish to communicate, please call our office by telephone.

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

In the event of an emergency, do you agree the Centre should take whatever action is deemed necessary, including the administration of First Aid, to ensure the health, well-being and safety of your child?

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.

Hidden

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. The records for your child may also be accessed by Centre staff and reviewed for purposes of accreditation. 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

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

I give my consent to:

Release

Obtain

Name of Social Worker

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

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 slash MM slash YYYY