Parent Referral Form - Kamloops Infant Development Society

Family Information

* Child

* DOB:

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Legal Guardians:

* Parent (1) Name:

Parent (2) Name:

* Street Address:

* Mailing Address:

* Phone:

* Email:

Foster Parent Information (if Applicable)

Name:

Address:

Phone:

* MCFD Involvement:

If Yes, Reason (ie support/child protection)

Name of Social Worker:

Is Social Worker Legal Guardian? YesNo

Referral Data:

* Date of Referral:

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Title and navigation
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<<	<	February 2026	>	<<

February 2026
	S	M	T	W	T	F	S
5	25	26	27	28	29	30	31
6	1	2	3	4	5	6	7
7	8	9	10	11	12	13	14
8	15	16	17	18	19	20	21
9	22	23	24	25	26	27	28
10	1	2	3	4	5	6	7

* Referral Source:

* Reason for Referral / Diagnosis:

* Age at referral:

Ancestry:

Birth Information

* Hospital:

* Gestational Age:

Birth Weight:

* Apgars:

* Physician (1) Name:

Physician (2) Name:

Medications:

Siblings Names:

Sibling and DOB:

Agencies Involved:

Agency and Professional Name (1) :

Agency and Professional Name (2) :

Does the family require an interpretor? YesNo

If YES, Language:

Are there any cultural or religious observances of which we should be aware?

Do you have any information that may indicate a potential risk to a home visitor?

Additional Comments:

Primary Criteria for Eligibility:

* Please tick if applicable: Infant referred is aged birth to six years
* Infant delayed or potentially delayed in one or more skill area(s) - see below
* Diagnosis. If so, see below
Intuitive feeling that something is not right
Family agrees to participate

Infant Delayed - provide detail:
Gross, fine motor, adaptive speech/language

Diagnosis - provide detail:

Comments / Other

Other Risk Factors

The following infants are at highest risk for development delays and should be referred if present:

Risk Factors: Prematurity < 37 weeks
Very Low Birth weight (VLBW) < 1500 gm with complications
Periventricular leukomalacia
Intraventricular Hemorrhage (IVH) Grade 3-4 Bleed
Congenital Anomaly
Genetic Conditions
Neonatal drug/alcohol exposure
Retinopathy of prematurity (ROP) Visual difficulties
Congenital infection
Birth asphyxia (moderate - severe)
Apgars less than 7 at 5 minutes
Seizures
Cardiac Anomaly
Prolonged Hypoglycemia that doesn't respond to Treatment
Increased Bilirubin level
Unusual muscle tone, asymmetry
Challenges with sleeping, feeling, crying
Failure to thrive (FTT)
NEC (Necrotizing Enterocolitis)
Multiple Births
Parental Health Issues (i.e. mental health issue, chronic medical condition)
History of abuse within the family
Foster care placements

* Electronic Signature

By selecting this checkbox, I affirm that the provided information is accurate and true, serving as my electronic signature.

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REFERRAL FORM