School Based Rehabilitation Service Referrals

Form Instructions

* Means this is a mandatory field.

Please do not leave any fields blank. Instead write N/A (for text fields) or 0000000000 (phone number fields) if you aren’t sure of the answer.

One Kids Place is in the process of upgrading our referral forms to make them more user friendly for our parents, caregivers and community partners.

If you receive an error message upon completion of the form please call Nicole at 1-866-626-9100, ext 3884 to ensure we have received it properly.

    Child's Information

    General Information

    Language(s) spoken by the child.


    Parent / Guardian Identification

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    Primary

    Other

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    Services Requested

    General Information

    Select all that apply.

    Select all that apply.

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    Child's Needs Details

    Please provide any information that you feel is important to understand the need for School Health Services.

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    e.g. preferential seating, modified expectations, extra time, equipment, access to a computer in the classroom, writing program, lined paper, pencil grips, etc.

    e.g. psychometric evaluation, language evaluation, etc.

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    Occupational Therapy Details

    Select all that apply.

    For more information about Occupational Therapy, please click here.

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    Physiotherapy Details

    Select all that apply.

    For more information about Physiotherapy, please click here.

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    Speech Therapy Details

    Select all that apply.

    For more information about Speech Therapy, please click here.

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    School Information

    Referral / Source Information

    First name of the person completing this referral.

    Last name of the person completing this referral.

    Your relationship to the child.

    Your phone number.

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    Please select today's date.


    "The personal information being collected on this form is collected under the authority of the Health Protection and Promotion Act, the Municipal Freedom of Information and Protection of Privacy Act & Personal Information & Electronic Documents Act.

    This information shall be used to ensure necessary health care measures are attained. Questions covering the collection of this information may be directed to One Kids Place 400 McKeown Ave. North Bay Ontario, P1B 0B2. Phone (705) 476-5437."