At Home Program

At Home Program

At Home Program Request for SchoolAged Extended Therapies form.
Welcome to Cherish's AHP Request Form Generator!

Currently the form is set up only for service by:
- Shay (Occupational Therapist)
- Dani (Speech Language Pathologist)
Guardian Email*
example@example.com
Cherish Clinic will submit by emailClient's guardian will submit

Part 1 Child

(age 5 and older, or upon school entry for children who will be 5 years on or before December 31st of the school year)
Child's Name*

First NameLast Name
Date of Birth*

YearMonthDay
Date
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Address

Street Address Line 2

City/TownState / Province

Postal Code
Specific Diagnosis (i.e.: type of impairment, location and degree of involvement)*
Part 2 Intent of Service
Post-surgical rehabilitation Please include letter from physician/surgeon/nurse practioner)Maintain or improve functional skill max $5760 for OT/PT/SLP; $1920 for chriopractic/massage)
Please indicate surgery date

YearMonthDay
Date
OCCUPATIONAL THERAPY (OT)SPEECH-LANGUAGE PATHOLOGY (SLP)
Start and End Dates*

YearMonthDay
Date
To*

YearMonthDay
Date
Total Funding Requested**

Part 4 Physician or Nurse Practitioner's Referral

(required only for massage and chiropractic requests)
Name of Physician or Nurse Practitioner
Signature Of the Physician or Nurse Practitioner

Clear
Date Signed (yyyy/mm/dd)

YearMonthDay
Date

PART 5 Functional Outcomes
Indicate the intended functional outcomes of your service for the child. Identify those outcomes that will be addressed through the use of a therapist assistant if applicable Refer to the Guidelines for Therapists — Writing Functional Outcomes, available at www.gov.bc.ca/athomeprogram Please use the reverse or attach an additional sheet if required.
Part 6 Coordination of OT/PT/SLP Services

The OT, PT and SLP services made available through the At Home Program are an enhancement to the therapy services provided by the child’s school/community based team (i.e. School-Aged Therapy Program and school district SLP services As a result, the requested OT, PT or SLP service must compliment and be consistent with the child’s established school/community based therapy plan.
Indicate the name and profession of the child’s therapy team member(s) (OT, PT, SLP) consulted*
Part 7 Therapist
Name of Therapist*

First NameLast Name
Profession
Licensed By
Registration/Licensing Number
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
YESNO
YESNO
TherapistAgencyOther:
This request has been developed in collaboration with the family and school/community therapist(s), and reflects meaningful outcomes for the child and family.
Therapist Signature

Clear
Date Signed (yyyy/mm/dd)

YearMonthDay
Date
Therapist Email*
example@example.com
C. Adddress
C. City
Type a question
Agency Name
Should be Empty:

Part 1 Child