Ontario Autism Program Urgent Response Services - New Client Intake Request

All fields are required unless marked “optional”

*Important* - This is not a crisis line. If this is an emergency, please call 911.

Peel

Halton

Dufferin County

Wellington County

Waterloo

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

Ontario Autism Program (OAP) Registration Confirmation

Is the child currently registered with the Ontario Autism Program (OAP)?

Yes No

Client Information

Date of Birth

Gender

Male Female

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 (optional)

Email (optional)

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)

Primary Language spoken in the home:

Does client identify as Indigenous?

Additional Information Required for OAP Urgent Response Services

Referral Date

Clear eligibility criteria

First Contact Date (Offered)

Date Level 1 Eligibility Screening Completed

Outcome of Level 1 Eligibility Screening

High Risk Factor Identified During Screening

Below fields are not required when client is Eligible for URS

Does the client/family meet the eligibility criteria for Crisis?

Was the client/family referred for other services? (Choose all that apply)

Service Navigation

Social Work

Coordinated Service Planning

OAP Foundational Family Services

None Identified

Other, please specify below