Northern Therapy Services Request Form – Northern Therapy Services

What community do you live in?

Name of individual that therapy is for

Age of that individual? (Date of Birth)

Name of Parent/Caregiver (if applicable)

What type of therapy services are you looking for?

Occupational Therapy (OT) Physiotherapy (PT) Speech-Language Pathology (SLP) Board Certified Behavior Consultant (BCBA) Rehabilitation Assistant (RA) Behavior Interventionist (BI) AthleticTherapist(AT),Kinesiologist/Exercise Therapist?

Primary concerns you’d like addressed

Service Type

Virtual Services In-Person Services Hybrid Services (some sessions in person and some virtual)

Contact Information – Name

Contact Information – Phone

Contact Information – Email

Additional details (diagnoses, urgency, recent surgery)

Is the condition related to an ICBC, WorkSafeBC, or other insurance claim?

Yes No

Do you know of any coverage available?

Yes No

Coverage – Adults (select all that apply)

Coverage – Pediatrics (select all that apply)

Jordan’s Principle At Home Program (MCFD) Autism Funding (MCFD) Private Insurance (if applicable, please specify agency) Private Payer (will cover own cost) Other/unknown

If Private Insurance, agency name

Anything else you’d like us to know?

Send me a copy of my responses.