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

Child's First Name*

Child's Last Name*

Date of Birth*

Gender*

Street Address*

Apt / Suite No.

City*

Province*

Postal Code*

Language*

Language(s) spoken by the child.

Service Language*

Parent / Guardian Identification

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Parent/Guardian {{rep-pg_index}}

Parent / Guardian First Name*

Parent / Guardian Last Name*

Email*

Phone Number *

Primary

Phone Number

Other

Is the address same as child's?*YesNo

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Street Address*

Apt / Suite No.

City*

Province*

Postal Code*

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Custody Status

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If "Other", please state special arrangements. [/group]

Services Requested

General Information

Services Eligible for Referral*

Select all that apply.

Are there any:*

Select all that apply.

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Please describe the behavioural concerns.*

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Please describe the safety concerns.*

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Please describe the medical concerns/diagnosis.*

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Please list any other agencies involved with the Child and describe their roles.*

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Child's Needs Details

Please describe the reasons for the service(s) you are requesting. How does this child's difficulties impact his/her participation in school routines or ability to receive instruction?*

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

Does this child have difficulty attending to task? Is he/she easily distracted?*YesNo

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Please describe.*

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Does this child receive help from the Resource Teacher or Education Assistant?*YesNo

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Please describe.*

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What modifications, if any, have you implemented in support of the child?*

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

What specialized testing, if any, has been done or is scheduled?*

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

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Occupational Therapy Details

Presenting Issues:*

Select all that apply.

For more information about Occupational Therapy, please click here.

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Physiotherapy Details

Presenting Issues:*

Select all that apply.

For more information about Physiotherapy, please click here.

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Speech Therapy Details

Presenting Issues:*

Select all that apply.

For more information about Speech Therapy, please click here.

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School Information

School / Daycare*

Grade*

Street Address*

Apt / Suite No.

City*

Province*

Postal Code*

Email*

Phone Number*

Fax

Referral / Source Information

First Name*

First name of the person completing this referral.

*Last Name*

Last name of the person completing this referral.

Relationship*

Your relationship to the child.

Phone Number*

Your phone number.

Is the address same as child's?*YesNo

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Street Address*

Apt / Suite No.

City*

Province*

Postal Code*

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Date of Referral*

Please select today's date.

I obtained verbal consent from the child's guardian to fill this referral form.

Signature

"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."