Booking a KidsAbility Intake Appointment-2024

Booking a KidsAbility Intake Appointment

Thank you for your interest in booking a KidsAbility Intake appointment. The information you share below will be shared with KidsAbility and will also be visible to the EarlyON professionals supporting our booking process. The information collected is private and confidential and will be used by KidsAbility under the terms and conditions outlined in their confidentiality statement. Outside of the conditions outlined in the confidentiality statement, KidsAbility will not share it with anybody without the parent/guardian's consent, except to protect life or safety or when permitted by law. In addition, this information will be added to KidsAbility’s electronic health record and the Ministry of Children, Community, and Social Services Database.
This intake appointment must be made and attended by the child's caregiver or legal guardian. The child does not need to attend the intake appointment and childminding can be provided through our EarlyON professionals if requested at time of appointment confirmation phone call. If you would like to book an appointment for more than one child, please submit the form separately. Please complete the form below and a team member will contact you.

*As a reminder, this is not a therapy assessment. If your child is already connected with KidsAbility’s services, the team may be able to support in exploring additional community resources & supports that are available, but this appointment will not impact or change the status of your services with KidsAbility.*
Caregiver/Legal Guardian Name*

First NameLast Name
Relationship to the Child*

CaregiverLegal GuardianNone of the above
If you answered "None of the above" to the above question, you cannot book this appointment with an Intake Social Worker from KidsAbility. You must be a caregiver or legal guardian of the child listed in question below.
Child Name*

First NameLast Name
Child Birthdate*

MonthDayYear
Date
Gender

FemaleMaleNon-BinaryTransgenderUnknownOther
1. What is your KEyON QR code number? (number on the back of your KEyON tag). If you do not have a KEyON tag, email us at earlyyearsinfo@ytr.ymca.ca to start the process. A KEyON tag is not required to book this consultation.
2. Child's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Caregiver/Legal Guardian filling out this form has the same address as the child*

YesNo
If not, please fill out Caregiver/Legal Guardian Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
3. Caregiver/Legal Guardian Phone Number*
Please enter a valid phone number.
4. Caregiver/Legal Guardian Phone Type*

HomeCellOther
5. Caregiver/Legal Guardian Email*
example@example.com
6. Second Caregiver/Legal Guardian Name

First NameLast Name
7. Relationship to the Child

CaregiverLegal GuardianNone of the above
8. Child’s custody status?*

Joint CustodySole CustodyThe Childrens Aid SocietyKinship AgreementNot Applicable- Not separated or DivorcedOther
9. What questions or concerns do you have that youare hoping to talk with an Intake Social Worker about?*
10. Is your child currently connected to KidsAbility already?*

YesNoUnsure
11. Do you need an interpreter for your Intake appointment? If so, what language do you require?*
12. Consent*

Caregiver or Legal Guardian with custody has consented to this service requestConsent to KidsAbility adding this personal health information to the KidsAbility electronic health record and the Ministry of Children, Community, and Social Services database.
13. Which EarlyON location you would like to book to attend?*
14. Which date you would like to book? (Please choose one only)*
14. Which date you would like to book? (Please choose one only)*
14. Which date you would like to book? (Please choose one only)*
14. Which date you would like to book? (Please choose one only)*
14. Which date you would like to book? (Please choose one only)*
14. Which date you would like to book? (Please choose one only)*
15. EarlyON professionals are able to provide childminding for up to two children ages 18 months and up during your appointment if needed. Do you need childminding during your appointment?*

Yes, I require childminding during my appointment.No, I will not be bringing my child(ren).
If yes, please indicate the names and age(s) of the child(ren) requiring supervision.
Should be Empty: