Online Request for Service

Please read before proceeding:

You will need to complete the form in one sitting.

Before beginning this form please make sure you have the following information available:

- Applicant's birthday
- Applicant's Personal Health Number
- Applicant's address including postal code
- Applicant's Key Contact Information (name, role, phone, address, email)
- Speech Language Pathologist or other Allied Health Professional information, if applicable

Surname

Preferred Name

Gender

Male
Female
Other

Given Name(s)

Birth Date

Personal Health Number

Please Indicate if Appropriate

Regular Service
CAYA Affiliate
CAYA Partner
Student Leaving School

Address Line 1

Address Line 2

City

Province

Postal Code

Phone

Email

Diagnoses, Conditions and/or Disabilities

What is the communication goal for this request?

Describe the Applicant's current communication skills

KEY CONTACT

Key Contact Name (first)

Key Contact Name (last)

Key Contact Role

Key Contact Phone

Key Contact Address

Key Contact Email

Family/Guardian

2nd Contact Name

2nd Contact Relationship

2nd Contact Phone

2nd Contact Address

2nd Contact Email

Speech Language Pathologist

Speech Language Pathologist Name

Speech Language Pathologist Role

Speech Language Pathologist Phone

Speech Language Pathologist Email

Occupational Therapist

Occupational Therapist Name

Occupational Therapist Role

Occupational Therapist Phone

Occupational Therapist Email

Other (specify)

Other Name

Other Role

Other Phone

Other Email

Day Program or School Information - if applicable

Name of Day Program or School

Address

Phone

Email

I certify the identity of

I certify that

has consented to this Request for Service

I certify that

has consented to the release of information and reports to CAYA for the purpose of improving their interpersonal communication.

I certify that

has agreed to communicate with CAYA staff in person and via telephone.

Comms consent

Yes
No

I certify that

has agreed to electronic communication.

Message consent

Yes
No

Referring Agent:

First Name

Last Name

Referrer consent

I certify that I am the person referring

Applicant

for CAYA services.

Name(s) that (copy)

Phone

Email

Date

Communication Assistance for Youth and Adults

Online Request for Service

Please read before proceeding:

Must be a resident of BC to proceed!

Day Program or School Information - if applicable

Referring Agent:

Please review and verify the information on this form to ensure that it is correct before clicking on the ‘submit’ button.

Information on this form will not be reviewed for accuracy until the client begins active service.