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Alternate Contact Information
Parent/Guardian Priorities – Reason for Referral
We work in collaboration with the Feeding and Swallowing Team at Kelowna General Hospital (KGH).
LARGE MUSCLE MOVEMENT
SMALL MUSCLE MOVEMENT (FINGERS, HANDS)
Do you wish to self-identify your child as:
Are you comfortable communicating in English?
Birth Information and Medical History
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
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
- 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:
Emergency Contact #1
Emergency Contact #2
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).
Ministry of Children and Family Development - MCFD
Interior Health Services/Public Health Nurse
Kelowna General Hospital
Children and Youth with Special Needs
Interior Health Children's Assessment Network - IHCAN
Okanagan Ability Centre
BC Children's Hospital
Sunnyhill Health Clinic
Other Service (Optional)
I authorize Starbright Children's Development Centre to obtain and/or release information regarding my child
from the persons/agencies listed above.
I understand and agree that this consent 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.