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All fields are required unless marked “optional”


This request is being submitted with the knowledge and consent of named parents/legal guardians. Have parents provided implied consent to information collection as per ErinoakKids Privacy Policy available at:

Client Information
Parent / Guardian / Family Information
Primary Person to notify (primary contact – will be the only person notified for services)
Next of Kin (secondary contact - optional)
Special Needs Information
Services Requested (select all that apply)

Services are provided for children with Physical or Developmental Disabilities, impairments with Communication, Hearing or Vision. Family must live in the catchment area of service.

Please visit our website at for detailed eligibility criteria and questionnaires where indicated.

Please be certain to check criteria for referral to ADRS on the website. If client does not meet eligibility criteria, please refer to community services (i.e. Preschool speech and language services, school board, etc.) If client is picked up for service and they do not meet eligibility criteria, they will be discharged from ADRS. They may be rereferred for service up until their 18th birthday.

Note: If technology is only needed at school, please follow up with your school for service options (e.g. Special Education Resources, School Health Support Services).


For URGENT service:

For PRIORITY service:

CONSENT TO REFERRAL, INFORMATION COLLECTION, TWO WAY COMMUNICATION (to be completed by school team or parent/legal guardian/student if over 18 years)

First 2 boxes must be checked for referral to be processed

Verbal Consent received by

Current Profile Check any that apply
Home/Personal Writing Needs:
School Writing Needs:
Writing Speeds:
Technology Use:

Adapted Access Required for:

Switch Access: Check any that apply
Non-writing computer use: check any that apply
Special Needs Information
Referral Source
Physician’s Referral Requirements

Required only for Medical Services or OHIP Pediatric Physiotherapy Clinic

Please fax any supporting attachments to 905-855-9451 i.e. reports, test/results, medical investigations, questionnaires, etc.)

Do you need more time to complete the referral?