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
Who will submit this application?

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
Indicate which type of service will be provided to the child:
Please indicate surgery date

YearMonthDay
Date
Part 3 Service Requested (please select one only)
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
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.
Have you previously provided therapy for this child?
Have you submitted an outcome summary of the previous therapy?
Have you submitted an outcome summary of the previous therapy?
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
Date Signed (yyyy/mm/dd)

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

At Home Program

Part 1 Child

Part 2 Intent of Service

Part 4 Physician or Nurse Practitioner's Referral

Part 6 Coordination of OT/PT/SLP Services

Part 7 Therapist