Pediatric Referral Form

Child's Information

First Name

Last Name

Date of birth

Age

Primary Language

School & Grade/Daycare

Child's Physician

Home Phone

Child's Address

Postal Code

Parent/Guardian's Information

Parent/Guardian's First Name

Parent/Guardian's Last Name

Relationship to child

Custody Do you have custody?

Yes No

Home Phone

Cell Phone

Work Phone

Email address

Preferred contact method

Home Phone

Cell Phone

Work Phone

Child's Information

Diagnosis/Date of Diagnosis

Other Relevant Background Information (e.g. medical, etc.)

Funding Information

Is child ready to start services immediately ?

Yes No

Has funding been approved?

Yes No

Funding Source (e.g., Jordan’s Principle, benefits, OAP) Select items that apply to the child.

Jordan’s Principle

OAP Funding

No Funding

Private

Benefits

Enter OAP Number

What date was child registered with Access OAP (if not registered, visit access OAP)

If your child has not been registered please go to https://accessoap.ca/ to complete immediately

Parent/Guardian's Information

If "No", complete the following details for at least one parent/guardian.

A Parent/Guardian's Information (required)

First Name

Middle Name

Last Name

Date of Birth

Another Parent/Guardian's Information (optional)

First Name

Middle Name

Last Name

Date of Birth

Speech-Language Pathology (SLP)

Are you interested in Speech-Language Pathology?

Yes No

Area/s of Concern (Reason for SLP Request): Select the items that are causing you concern.

Language

Is your child using words and sentences? Does your child understand directions?

Speech sounds

Is your child difficult to understand? Are there sounds your child isn’t making properly?

Social skills

e.g., ability to interact with others, play skills)

Additional Information/Comments

Has the child received previous speech language pathology therapy services?

Yes No

Provide name of agency

Is the child presently receiving speech language pathology therapy services through another agency?

Yes No

Provide name of agency

Has the child had their hearing screened and/or tested?

Yes No

OCCUPATIONAL THERAPY (OT)

Are you interested in Occupational Therapy?

Yes No

Area/s of Concern (Reason for OT Request) Select the items that are causing you concern.

Fine Motor/Visual Motor

e.g., printing, cutting

Sensory

Activities of Daily Living

e.g., shoe laces, zippers, buttons, opening snack containers

Additional Information/Comments

Has the child received previous occupational therapy services?

Yes No

Provide name of agency:

Is the child presently receiving occupational therapy services through another agency?

Yes No

Provide the name of the agency

APPLIED BEHAVIOUR ANALYSIS (ABA)

Are you interested in Applied Behavour Analysis (ABA)

Yes No

Are you ready to start services immediately?

Yes No

Area/s of Concern (Reason for ABA Request) Select the items that are causing you concern.

Adaptive Skills

Feeding

Toileting

Communication

Social Skills

School Readiness

Academic Remediation

Parent Training

Other

Service Model Requested Select your preference for services

Full-Time ABA

Part-Time ABA

In Centre

Parent Training Only

School Based ABA

Home Based ABA

Parent Training

Weekend ABA

Additional Information/Comments

Has the child received previous ABA therapy services?

Yes No

Provide name of agency

Is the child presently receiving ABA therapy services through another agency?

Yes No

Provide the name of the agency

Your information will be encrypted.