Sundrops Referral Form

Parent Aware of Referral
Aboriginal Family
*The cutoff date for referral for therapy services is February 28th of the child’s pre-kindergarten year*
Referral Date

Date of Birth
Preferred Pronoun

(0-5 for SLP, OT, PT, IDP; 0-12 for SCD)
Mailing Address (if different)
Date of Birth

The private and personal information collected on this form is used to determine eligibility and appropriateness of services to be provided. Non-identifying statistical information may be collected, collated and distributed to support requests for funding, advocacy, resource allocation and measuring outcomes. Please refer to the Personal Information Protection Act