Camper Referral 2021 – Therapist/Professional Camper Referral 2021 - Therapist/Professional For therapist and/or professional (OT, COTA, PT, PTA, SLP, SLP aide, TVI, O&M certified, D/HoH support) of child being referred for potential participation in Bay Cliff Health Camp for summer 2021. Complete this form and submit, or you have the option (at the bottom of the form) to save and return later. All fields marked with * are mandatory. You will get an immediate notification of receipt (or link to access later). If you don't, please reach out to Bay Cliff Health Camp for support (906)345-9314 or jpinar@baycliff.org Child's Name* First Last Therapist/Professional Name* First Last Therapist/Professional Credentials*(ex. MS, OTRL - TVI - PT, DPT - etc)Email* Address (If interested in receiving future printed communications from Bay Cliff): Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone*We will only phone you for questions specific to this child/this summer, after trying the email provided.Type of therapy/professional support you provide to child*Occupational Therapy ServicesSpeech & Language Therapy ServicesPhysical Therapy ServicesBlind/Low Vision SupportDeaf/Hard of Hearing SupportOther Therapy/ies child receives* Occupational Therapy (direct service) Physical Therapy (direct service) Speech & Language Therapy (direct service) OT Consultation PT Consultation SLP Consultation Blind/Low Vision Support Deaf/Hard of Hearing Support N/A (No additional services) Other Check any service that the child has currently. This will help Bay Cliff make sure we get professional servicer information to best inform therapy and camp services this summer.If "other" service was selected, please specify:*EligibilityBay Cliff Health Camp has developed a set of criteria to determine if children will be successful in our typical summer program. The entire criteria are available on our website, and several key indicators are included below. Check each box that is correct (aka the child 'is', 'does' or 'has') and add any notes necessary for clarification at the bottom. All Camper Criteria (check all boxes that are 'true' for child being referred):* 3-17 years of age Requires no more than minimal daily nursing care Breathes without ventilator Consistently communicates yes/no with everyone Needs skilled therapy intervention (OT/PT/Speech) Working on a life skill (Basic ADL [bathing, dressing, grooming] or more complex) Stable medications for behavior management (if applicable) No recent or major violence/aggression Regularly attends school for full day, 5 days/week Remains with group (no elopement) Tolerates variety of environments (loud, busy, bright, hot) Tolerates regular schedule (full day) Tolerates changes to schedule Notes (clarification from Eligibility Criteria, if any boxes were not checked):Information for therapists at Bay CliffDo you provide this child with any equipment or materials to promote success?*YesNoIf yes, please specify:*If yes, would you be able to send home these items for the child to use this summer?*(or indicate if you are aware that the family/child has a piece of equipment to use).Equipment/Support Materials - Please provide any insight and/or recommendations from your experience working with this child, for therapists working virtually to support them:*Does this child have difficulty swallowing?*YesNoPlease specify dysphagia protocol/precautions in place:*If 'yes' was indicated for swallowing difficultyConcerns/recommendations for this child related to swallowing?*If 'yes' was indicated for difficulty swallowing.Does this child require sensory processing support in your setting?*yesnoWhat sensory processing supports would you expect this child to need in a virtual camp (and therapy) setting?*Concerns or recommendations for this child related to sensory processing?*Any medical precautions for Bay Cliff therapists to be aware of?*yesnoPlease specify:If 'yes' was indicated for medical precautionsWhat support do you provide to promote success in the school setting?*What support would you expect this child to need in a virtual therapy/camp setting?*Recommendationsfor therapist/professional at Bay Cliff Health Camp this summer!Goals:*Treatment (Methods, programs that work etc.):*Carryover (with parent) and Other:*Paperwork Drop files here or Accepted file types: jpg, png, pdf, . IEP and recent progress report.CAPTCHANameThis field is for validation purposes and should be left unchanged. Theresa Campana2021-01-22T14:56:10-05:00
