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. Child's Information General Information Child's First Name* Child's Last Name* Date of Birth* Gender*MaleFemaleTwo SpiritNon Binary Street Address* Apt / Suite No. City* Province*AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaOntarioPrince Edward IslandQuebecSaskatchewan Postal Code* Language* Language(s) spoken by the child. Service Language* Parent / Guardian Identification 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 Street Address* Apt / Suite No. City* Province*-- Please Select --AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaOntarioPrince Edward IslandQuebecSaskatchewan Postal Code* Add parent/guardian Remove parent/guardian Custody Status-- Select --Other If "Other", please state special arrangements. Services Requested General Information Services Eligible for Referral*Occupational TherapyPhysiotherapySpeech-Language Pathology Select all that apply. Are there any:*Behavioural ConcernsSafety ConcernsMedical Concerns/DiagnosisOther Agencies Involved with ChildUnknown Select all that apply. Please describe the behavioural concerns.* Please describe the safety concerns.* Please describe the medical concerns/diagnosis.* Please list any other agencies involved with the Child and describe their roles.* 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 Please describe.* Does this child receive help from the Resource Teacher or Education Assistant?*YesNo Please describe.* 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. Occupational Therapy Details Presenting Issues:*Past OT recommendations are no longer applicable/appropriate for the child.Child requires assessment for adaptive equipment.Child requires desk/chair modificationsChild requires ADL devices/equipment (e.g. adapted feeding utensils).Pencil grasp/Pencil control skills.Scissor use.Printing legibility (e.g. letter sizing, spacing between words).Printing speedEye-hand coordinationHand dominance.Sensory (e.g. easily upset/distracted by loud or unexpected noises, bright lights, avoidance/dislike the feeling of certain objects.Seeking tendencies (e.g. mouthing or sniffing objects).Rocking, swinging movements. Select all that apply. For more information about Occupational Therapy, please click here. Physiotherapy Details Presenting Issues:*Difficulties have an impact on the child’s safety or ability to participate in school curriculum/routine.Child has delays resulting in inability to perform everyday age appropriate school related tasks.Child is 5 years or older and has a 12-18 month gross motor functional delay compared to age group.Child has issues with Range of Motion (ROM) and/or joint contractures that impact ability to participate in school curriculum/routine.Child requires equipment which enables mobility/ROMChild has coordination problems affecting transfers, gait, postural control and safety.Educator is able to apply interventions/teaching, provided by PT.Child has lung secretions impacting breathing ability at school. (Must have a medical practitioner to provide care orders). Select all that apply. For more information about Physiotherapy, please click here. Speech Therapy Details Presenting Issues:*Child is 5 and older and has difficulties articulating any of the following: m, h, w, p, b, t, d, n, f, y, (yellow), k and/or gChild is 6 and older and has difficulty articulating any of the above sounds, and/or v, ng, I and I-blends (pl, bl, fl, kl, gl), s and s-blends (sp, sm, sn, sk, sl, sw, st) and/or sh, ch, th, j (jump).Child is 7 and older and has difficulty articulating any of the above sounds, and/or z, r.Child stutters.Child’s voice sounds nasal, breathy or hoarse.Child’s pitch is too high or too lowChild’s voice is too loud or too quietChild has a medical referral for a swallowing assessment.Delay of receptive and/or expressive language (North Bay & Parry Sound Schools).Augmentative Communication needs (North Bay & Parry Sound). Select all that apply. For more information about Speech Therapy, please click here. School Information School / Daycare* Grade* Street Address* Apt / Suite No. City* Province*AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaOntarioPrince Edward IslandQuebecSaskatchewan 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 Street Address* Apt / Suite No. City* Province*AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaOntarioPrince Edward IslandQuebecSaskatchewan Postal Code* Date of Referral* Please select today's date. I obtained verbal consent from the child's guardian to fill this referral form. Signature Clear Send Form "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."
