Early Intervention Enhancement Referral

Early Intervention Enhancement Referral

All information in this form is secure and will only be shared with our Child and Family Services intake personnel. There are no self-referrals to this program.
Personal Information
Child Full Name*

First NameLast Name
Child Birthdate*

MonthDayYear
Parent #1 Full Name*

First NameLast Name
Birthdate*

MonthDayYear
Cell phone*
Ten digit number
Email*
Note: A copy of this referral will be sent to the parent(s)/guardian at this email address.
Preferred method of contact*

PhoneEmailMail
Parent #2 Full Name

First NameLast Name
Birthdate

MonthDayYear
Cell Phone
Ten digit number
Email
Note: A copy of this referral will be sent to the parent(s)/guardian at this email address.
Preferred method of contact

PhoneEmailMail
Child resides with:*

Parent #1Parent #2BothOther
Child primary home address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Languages Spoken
Please list all languages spoken in the home*
Do any family members identify as Indigenous (First Nations, Métis, or Inuit)?*

YesNo
If yes, please specify which Nation, community, or group are they part of?
Please write the name above
Would the family like to include an Elder or Knowledge Keeper they know or already work with? This could be someone from their Nation or community.

YesNoUnsure
Services
Which services are the family currently involved with?*

Occupational TherapyPhysical TherapySpeech Language TherapyBehaviour ConsultationFASD Key Worker ServicesEarly Childhood Mental Health ServicesIDP/AIDPSCD/ASCDCYSNN/AOther
Referral Information
Reason for referral (check all that apply)*

Additional coordination of service would be beneficialThe family would benefit from more intensive supportCurrent supports are not effectiveConcerns the child will be excluded from community school programming
Current supports are not effective - please explain
Concerns the child will be excluded from community or school programming - please explain
Complex needs of child*

BehaviouralEmotionalSocialPhysicalDevelopmentalHealth
Complexities in the family situation that may make the child more vulnerable*

IsolationLow incomeFamily conflict or violenceParent/caregiver health issuesParent/caregiver capacityOther
Please expand on other important information to consider (e.g. circumstances that may make a family more vulnerable, natural support available to the family, etc.)
Family expecting follow up - I have informed this family of my referral to the above services and they are expecting to be contacted for each service requested*

YesNo
Consent to share referral status - the parents/guardians have given consent for the status of the referral to be shared with the person and/or organization making the referral. Note: a copy of this referral will be sent to the parent(s)/guardian.*

YesNo
Name of Referral Source*
Referral Agency (if applicable)
Phone Number*
Please enter a valid phone number.
Referral Agency's Email*
example@example.com
Date of Referral*

MonthDayYear
Authorization
Signature*
Date*

MonthDayYear
Click below to acknowledge that you have read and understand how the information in this form is collected and used.*

This form collects information for the sole purpose of informing Child and Family Services eligibility. By checking this box, you verify that the information collected is accurate to the best of your knowledge and that you understand that we will use the information to contact the named parent/guardian.
Should be Empty:

Early Intervention Enhancement Referral

Personal Information

Languages Spoken

Services

Referral Information

Authorization