Notice to change services and supports from Autism Funding to Family Connections Centre

The personal information collected on this form will be used for the purpose of providing funds through Autism Funding Programs: Under Age 6 Program and Autism Funding Programs: Ages 6-10 Program under the authority of the Supply Act and guided by the Freedom of Information and Protection of Privacy Act. Any questions about the collection, use or disclosure of this information should be directed to the Autism Funding Community Liaison/Quality Assurance Officer, toll free at 1-877-777-3530, PO Box 9776 Stn Prov Govt, Victoria BC V8W 9S5.

This form is used to notify the Autism Funding program that you, as the individual that has signed the Autism Funding Agreement, have decided to receive future services from a Family Connection Centre.

Note: If you have multiple children receiving Autism Funding, you must submit a separate form for each child.

Child's First NameMissing or incorrect value

Child's Middle Name(s)

Child's Last NameMissing or incorrect value

Date of Birth

Missing or incorrect value

The parent/guardian that has signed the Autism Funding Agreement:

Agreement Signatory's First NameMissing or incorrect value

Middle Name(s)

Agreement Signatory's Last NameMissing or incorrect value

What is your current mailing address?Missing or incorrect value

What is your email address?Missing or incorrect value

Confirm email address:Missing or incorrect value

Year

Please check the following statements:

Next steps:

Missing or incorrect value

You will receive either a message in My Family Services or a letter in the mail which confirms the end date of funding. You may continue to use Autism Funding and submit new requests until that date.

Service providers continue to have 6 months from the date of service and/or date of equipment purchase to submit an invoice.

You may decide after receiving goal focused services from the Family Connection Centre to resume Autism Funding. To do so, you will be asked to inform the Autism Funding program in writing. You will be asked to provide the end date or confirm that all goal focused services at the Family Connections Centre have ended.

Signature

Missing or incorrect value

Date signed

To submit your application, click the Email button below when all required information is provided. A copy of this form will be emailed to the address you provided above. Please wait up to 15 minutes for your confirmation email to arrive.

Notice to change services and supports from Autism Funding to Family Connections Centre

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