Behavioural Intervention Program Referral Form

Please note: VCDA offers this service to families who live in Kings and West Hants Counties. The program supports families who have children 3 years of age to school entry who may be at risk developmentally and emotionally due to challenging behaviors.

FAMILY INFORMATION:

Name of Child

Date of Birth:

Age at Referral

Checkbox Group

Male

Female

Names of Parents or Guardians

Please Indicate With Whom the Child Resides

Custody Agreement in place?

Yes

Civic Address

Community

County

Postal Code

Mailing Address if Different than above

Phone

Previous Family Contact with VCDA - i.e. siblings? - If yes please specify below

Yes

Reason for Referral

Other Professionals and Agencies Seen/Seeing

REFERRAL SOURCE

Are parents aware of this referral?

Yes

Name

Agency/Position

Date

Phone

Fax

Mailing Address

How did you know to contact Valley Child Development Association? (Professional, Website, Brochure, Friend, other)