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 www.mybrainonline.org. Alternatively, you can also contact the program coordinator directly at (604) 451-5511 Ext. 1470 or via e-mail at Whitney.Macrae@bc-cfa.org to discuss resources and supports that may be available within your community.


Middle Name:Date of Birth:(DD/MM/YY)*Gender:*Preferred Pronoun:

Personal Health Number:*

Guardian 1 First Name:*

Guardian 1 Last Name:*

Guardian 1 Email:

Guardian 1 Mobile:

Guardian 1 Phone:*

Guardian 1 Work Phone:

Guardian 2 First Name:

Guardian 2 Last Name:

Guardian 2 Email:

Guardian 2 Mobile:

Guardian 2 Phone:

Guardian 2 Work Phone:

Does family require interpreter?:

Language Specification:

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

Client/family identify as indigenous?:

Referral Reason:*

Referrer First Name:*

Referrer Last Name:*

Referral Phone Number:*

Referral Fax Number:

Primary Community Physician:

Admission Date:(DD/MM/YY)

Anticipated Discharge Date:(DD/MM/YY)

Recommended Service and Intensity:

Child & Family Needs:

If this is a community referral please review the two statements below.

Consent for Service:
“The parent/guardian has provided consent for me to make this referal on their behalf and given BCCFA permission to obtain pertinent information regarding their child.“

Discussed info with family:
“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“