*Please note you must download/save to computer, then fill out, save and send.
Early Childhood Mental Health Program Referral (Ages 0-6)
Family Connections Services Team Referral: OT, PT, Speech, IDP, SCDP, EYOP
Family Connections OT & PT Consent to Services
Family Connections OT & PT Information Release
Mental Health Program ages 6-12 Extended Therapy Services
OT Extended Therapy Services Referral (other funded services)
OT Extended Therapy Services Information Release (other funded services)

Where do I send my connection (referral) form?

  • Completed forms can be faxed to 250-723-7349 or emailed to programs@outreachtherapy.org 
  • if you would like help completing these forms, please contact us at 250-723-1117. 

How do I connect to the services?

  • You do not need a doctor to refer you, you can call our office and refer over the phone.
  • Parents, relatives, teachers, doctors, health care professionals, child care professionals can all connect to our services, but with parent or guardian consent.
  • Many of our community partners, including daycares, doctors, public health nurses and other local agencies have copies of these forms and can fill the out  on your behalf.