GENERAL – NEW CLIENT INTAKE REQUEST

All fields are required unless marked “optional”

Peel

Halton

Dufferin County

GENERAL CONSENT

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: erinoakkids.ca/privacy

Consent Received Yes No

Client Information

Date of Birth

Gender

Male Female

Health Card #

Version Code

Child's Name

Address

Unit #

Street #

Street Name

City

Postal Code

Parent / Guardian / Family Information

Primary Person to notify (primary contact – will be the only person notified for services)

Phone # 1

Phone # 2

Address Copy from Client

Unit #

Street #

Street Name

City

Postal Code

Next of Kin (secondary contact - optional)

Phone # 1

Phone # 2

Address Copy from Client

Unit #

Street #

Street Name

City

Postal Code

Client Lives with

Both Parents One Parent Foster Parent Other (Specify)

Other

Full Name any Siblings who are receiving services at ErinoakKids (optional)

Primary Language(s) spoken in the home:

Identify School Board, if applicable (optional):

Identify School name (if applicable):

Identify Daycare name (if applicable):

Special Needs Information

Children’s Protective Services, Agency Name: (optional)

Caseworker’s Name: (optional)

Phone Number (Optional)

Are Interpreter Services required? Yes No Unsure

Allergies Yes No

Epipen required? Yes No

Is this child receiving or waiting for services in the community? Yes No Unsure

Diagnosis Yes No

Identified Issues/Areas of Concern

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 https://www.erinoakkids.ca/ for detailed eligibility criteria and questionnaires where indicated.

Assistive Devices Resource Service (ADRS)

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.

Assessment to address technology needs at: Home Home and School

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).

ADRS History New ADRS Client Previous ADRS Client Seating Clinic Client (current or past)

Communication Skills: Verbal Non-Verbal Verbal Challenges (explain):

Other

Any concerns regarding vision? Yes No

Any concerns regarding hearing? Yes No

Does your child require a mobility device? (i.e. Walker, wheelchair) Yes No

For URGENT service:

Significant behaviors, at risk of injury to self or others, attributed to lack of ability or limited ability to communicate

Degenerative condition, anticipate significant decrease in functioning that will impact ability to communicate with speech and/or writing within 1-2 years

For PRIORITY service:

Major transition even anticipated within 12 months (i.e. new school, aging out of ErinoakKids, etc.)?

Additional Information you wish to provide:

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

1. This request for referral is being submitted with the knowledge and consent of Student/ Parent/ Guardian.

Yes No

2. Student/Parent/Guardian grant consent to have ErinoakKids enter referral information into its data base.

Yes No

3. Student/Parent/Guardian grants consent for ErinoakKids to exchange and share information with the school/daycare and school board that the child is attending within the ErinoakKids catchment area and the school board and the school/daycare will share information with ErinoakKids

Yes No

Verbal Consent received by

Name

Date

School/Daycare Name

School/Daycare Phone

School/Daycare Contact Name

School/Daycare Email

Face-to-Face Communication

Current Profile Check any that apply

Communication challenges are experienced at:

Home

School

Client demonstrates cause and effect skills/awareness.

Client initiates/demonstrates a desire to communicate:

Client intentionally communicates:

Which of the following does the client use to communicate?

Objects

How many objects can the client choose from at a time?

2 3 or more

Gestures and/or signs

Approximately how many gestures/signs does the client use?

Less than 20 20-50 More than 50

Do they combine 2 or more gestures and/or signs to communicate? Yes No

Photographs and/or PCS (Picture Communication Symbols)

Approximately how many photographs/PCS does the client use regularly?

Less than 20 20-50 More than 50

Do they combine two or more photographs/PCS to communicate? Yes No

PECS (Picture Exchange Communication System)

What level of PECS is client using?

How many symbols does the client use in their PECS binder?

Words or word approximations

Approximately how many words/word approximations does the client use?

Less than 20 20-50 More than 50

Do they combine two or more words/word approximations to communicate? Yes No

Are words used spontaneously or in imitation only?

If making choices from objects, photographs, PCS how do they choose ?

Point

Reach

EyeGaze

Other

Other speech services involved: (i.e. school SLP/private SLP )

Agency/service name:

SLP and contact information

Additional information and/or past communication device/system use:

Written Communication

Home/Personal Writing Needs:

Homework

Journal

Social messaging/email

Lists/notes

Creative writing

Other

School Writing Needs:

Language Arts

Essays/Projects

Journal

Math

Spelling

Worksheet

Note taking/Copying

Homework

Other

Academics/Literacy:

Writing grade level

Reading grade level

Writing Speeds:

Handwriting

Keyboarding

Technology Use:

Please describe previous and/or current use of technology to support writing

Adapted Access

Adapted Access Required for:

Face-to-Face communication system

Computer for non-writing activities (mouse control, single switch access)

Access to toys, Electronic Aids for Daily Living (EADLs)

Switch Access: Check any that apply

Client is motivated by/demonstrates interest in:

Client demonstrates cause and effect skills/awareness.

Client has a body part with consistent/accurate movement:

Client has tried switches (switch type?):

Client tried simulated switch use:

Activities client has tried switches with:

toys with movement

toys with music/sound

toys with lights

computer (see next section)

speech generating device:

Other

Non-writing computer use: check any that apply

Client has tried using a standard keyboard yet has physical difficulty accessing it

Client has tried using a standard mouse yet has physical difficulty handling it.

Client has tried alternatives to a standard keyboard and/or mouse:

Client would like to use a computer:

to play keyboard/mouse based games

to access early education software

to develop keyboarding skills

Other

Special Needs Information

Audiology Services

Infant Hearing Audiology (Suspected or permanent hearing loss - please fax all relevant reports to (905) 855-9451)

Audiology - Fee for Service: Birth to age 19 and/or not eligible through the Infant Hearing Program

Medical Services Medical doctor referral required. Please fax all relevant reports to (905) 855-9451

ASD Diagnostic Clinic – query autism assessments (client must be under 16 years at time of referral)

Developmental Consultation Clinic – Clients with suspected or confirmed developmental or genetic delays/disorder requiring assessment/follow up

Neuromuscular Clinic – Clients with suspected or confirmed Neuromuscular Disorders requiring assessment/follow up

Orthopaedic Clinic – Clients with physical or developmental problems requiring surgical assessment and/or management of musculoskeletal problems

Botox - Clients with spasticity and or dynamic contractures that would benefit from Botox injection

Cerebral Palsy-Neuromotor Clinic

Occupational Therapy

Physiotherapy

OHIP Pediatric Physiotherapy Clinic for Torticollis (Physician referral required)

Respite Services - refer to our website for information and the referral process for day and overnight Respite opportunities – https://www.erinoakkids.ca/all-services/family-supports/respite-services (fax the applicable Questionnaire.)

Vision Services (fax diagnostic report of visual impairment)

Preschool Speech and Language – after finishing here please complete the Communication Checkup

Fetal Alcohol Spectrum Disorder (FASD) Services

Referral Source

Parent/Guardian Medical Community Agency Other

Referral Source Name and Contact Information

Physician’s Referral Requirements

Required only for Medical Services or OHIP Pediatric Physiotherapy Clinic

Physician’s Name

Physician’s Signature

Tel #

Fax #

Billing #

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