Please note, we provide rehabilitation services for children and youth under 19 who have sustained an acquired brain injury within the last year, reside in BC with the right to live permanently in Canada, and who do not have access to third-party funding (ICBC, Crime Victim Assistance, Private Insurance)

If you are looking for information for a child or youth who has sustained a concussion please refer to our website for resources or information regarding concussion. Please visit our website at Alternatively, you can also contact the program coordinator directly at (604) 451-5511 Ext. 1470 or via e-mail at to discuss resources and supports that may be available within your community.

Middle Name:


Other Gender Specification (if “other” is selected):

Preferred Pronoun:

Guardian 1 Mobile:

Guardian 1 Email:*

Guardian 2 First Name:

Guardian 2 Last Name:

Guardian 2 Phone:

Guardian 2 Mobile:

Guardian 2 Email:

Admission Date:(DD/MM/YY)

Anticipated Discharge Date:(DD/MM/YY)

Referrer First Name:*

Referrer Last Name:*

Referral Agency/Organization:

Referral Phone Number:*

Referral Fax Number:

Primary Community Physician:

Recommended Service and Intensity:

Language Specification:

If you have selected “Other” for language specification, please specify:

If this is a community referral please add your contact information in this box and review the two statements below.

I have discussed the above information with the child’s parents/guardians, and they understand that a representative of the Program will contact them to provide further program and service information: