Respite Services - Ages 3-12 - BEFORE completing our respite application form, please review our criteria to make sure that our services are appropriate for your child.

Fees

Due upon confirmation of space

$50 per hour
All services are in centre

Children with a primary and/or secondary diagnosis of Autism are eligible

Child must be comfortable and be able to be successful in a group environment

Maximum 1:1 support is available for children- children requiring 2:1 support please email respite@creativetherapyassociates.ca

Child Information- Ages 6-12

First name

Last name

Date of birth

Parent or Guardian Information

First name

Last name

Home phone number

Cell phone number

Email address

Relationship to child

Emergency Contact Information

First name

Last name

Home phone number

Cell phone number

Email address

Relationship to child

Medical History

Is the child diagnosed with ASD?

Yes No

Please list all diagnosis and/or any medical information

Does the child have allergies?

Yes

List allergies below

List all known or suspected allergies

Does the child have an Epi Pen?

Yes

List allergies below

No No known allergies

What medications is the child taking (if any) and for what conditions? Include the dosage and amounts.

Has the child been diagnosed or experienced seizures? Please explain type of seizure(s) and triggers for seizures

Yes No Not Applicable

Additional medical information

Activities of Daily Living and Personal Care Requirements

Checkbox list Please Indicate if your child requires assistance for each of the activities listed below. Accuracy in filling out this section is essential to planning care.

Eating

Washing Hands

Dressing

Mobility

Toileting

Transferring on and off the toilet

In and out of wheel chair

Personal safety

Additional Information

Behaviours and Coping Patterns

Please select all behaviours/coping patterns

Aggression towards self

Aggression towards others

Elopement (exiting or running away)

Fire Setting

Sexualized Behaviours

Refusal

Property destruction

Other relevant information

(this information is to gain a better understanding of how to best support your child)

Communication Method

Verbal Language AAC Device Picture Exchange System Gesturing/Pointing Emerging Language

Other relevant information

Toileting

Is your child toilet trained

Yes No

Information related to elimination needs for your child

Respite Days

Full Day Respite Required?

Yes No Half Days only

Choose your preference for respite days

Weekdays( Mon-Fri) Weekends (Sat-Sun)

Preferred Day(s)

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Confirmation of Accuracy and Truthfulness

I confirm that the information provided in this intake form is accurate, complete, and truthful to the best of my knowledge. I understand that any false or misleading information may affect the services provided. I agree to update Creative Therapy Associates promptly if any changes occur to the information provided.

I agree to the above statement attesting to confirmation of accuracy and truthfulness

Yes

Creative Therapy Associates will contact you as soon as availability opens. Before starting services, payment will be required, and a formal intake meeting will be scheduled. Due to the high volume of calls and inquiries, we are unable to respond to phone calls or emails regarding service availability until your child's space becomes available. If you need to make changes to your form, please email respite@creativetherapyassociates.ca.

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