Child development referral form

The cutoff date for referral for therapy services is January 30th of the child's pre-kindergarten year

Child's name:(Required)

First Last

Child's birth date:(Required)

MM slash DD slash YYYY

Gender:

Male

Female

Prefer to self describe:

Pronouns:

Does the child have a diagnosis and/or are you or the child’s parent/guardian wondering about autism, ADHD, or developmental delays?

Yes

No

If yes, please specify:

The child lives with:

Both parents

One parent only

Foster family

Other:

The legal guardian for this child is:

Both parents

One parent only

Gov't guardian

Other

Primary contact - parent/legal guardian/foster family/other:(Required)

First Last

Physical address:

Street Address City Postal Code

Mailing address (if different include PO box#):

Street or PO box # City Postal Code

Phone (home):

Work:

Cell:

Primary email address:(Required)

Primary contact - consent to receive email communications from Clements Centre:(Required)

Yes

No

Secondary contact - parent/legal guardian/foster family/other:

First Last

Address:

Street Address City Postal Code

Phone (home):

Cell:

Work:

Preferred email(s):

Secondary contact - consent to receive email communications from Clements Centre:(Required)

Yes

No

Is the child Indigenous (that is, First Nations, Métis, or Inuk?):

Yes

No

Language(s) spoken at home:

Would an interpreter be helpful?:

Yes

No

Is the child attending daycare?

Yes

No

Daycare name:

Days and hours of attendance:

Professional contact information

Family doctor

Family Doctor Phone:

Pediatrician

Pediatrician Phone:

Other

Other Phone:

Services or consultations requested:

Please provide specific reasons why you are requesting services or consultations. Use ‘additional comments" section if more space is needed.

Infant development

Yes

No

The Infant Development Program supports families with children birth to age three who have a developmental delay or are identified at risk for delay. In specific instances, service may be extended up to school entry. Goal oriented support is provided in the family's home or community.

The Infant Development Program supports families with children birth to age three who have a developmental delay or are identified at risk for delay. In specific instances, service may be extended up to school entry. Goal oriented support is provided in the family's home or community.

Feeding services

Yes

No

Clements Centre feeding services are not an urgent care service. Families with urgent feeding needs are directed to begin receiving services with the appropriate service provider. Clements provides feeding assessment and consultation services for children between 0-5 years of age and typically consists of an SLP and OT team. The team aims to work collaboratively with other service providers involved such as the family doctor, pediatrician, dietitian, public health nurse, and lactation consultant.

Clements Centre feeding services are not an urgent care service. Families with urgent feeding needs are directed to begin receiving services with the appropriate service provider. Clements provides feeding assessment and consultation services for children between 0-5 years of age and typically consists of an SLP and OT team. The team aims to work collaboratively with other service providers involved such as the family doctor, pediatrician, dietitian, public health nurse, and lactation consultant.

Occupational therapy

Yes

No

Occupational therapists look at functional areas of children’s development that they may need additional support in. These areas include self-care (i.e. bathing, dressing, feeding, toileting, sleep), productivity (i.e. participating in group settings, sensory processing challenges, fine and visual motor skills, attention to tasks) and leisure (i.e. play, social interactions).

Occupational therapists look at functional areas of children’s development that they may need additional support in. These areas include self-care (i.e. bathing, dressing, feeding, toileting, sleep), productivity (i.e. participating in group settings, sensory processing challenges, fine and visual motor skills, attention to tasks) and leisure (i.e. play, social interactions).

Physical therapy

Yes

No

A physiotherapist provides treatment, assessment, recommendations and training in age-appropriate activities to support children with gross motor skills. Physiotherapy can help to correct and prevent disabilities associated with disease, injury, congenital deformity or developmental delay.

A physiotherapist provides treatment, assessment, recommendations and training in age-appropriate activities to support children with gross motor skills. Physiotherapy can help to correct and prevent disabilities associated with disease, injury, congenital deformity or developmental delay.

Speech language therapy

Yes

No

Speech language pathology supports the development of skills related to speaking, communicating and swallowing. This includes areas such as developing speech sounds and speech clarity, language understanding and expression, social communication, imaginative play skills, literacy, appropriate use of voice, smooth stutter-free speech, and feeding/swallowing.

Speech language pathology supports the development of skills related to speaking, communicating and swallowing. This includes areas such as developing speech sounds and speech clarity, language understanding and expression, social communication, imaginative play skills, literacy, appropriate use of voice, smooth stutter-free speech, and feeding/swallowing.

Supported child development

Yes

No

Supported Child Development (SCD) is a community-based program that assists families of children with extra support needs to access inclusive child care that meets the child and family’s needs.

Supported Child Development (SCD) is a community-based program that assists families of children with extra support needs to access inclusive child care that meets the child and family’s needs.

Additional comments:

Referral source

Name:

First and last

Date:

MM slash DD slash YYYY

Phone number:

Email:

Relationship to the child who is being referred:

I confirm that I have reviewed and discussed this referral with the child's family prior to submission:

Yes

No

The private and personal information collected on this form is used to determine eligibility and appropriateness of services to be provided. Non-identifying statistical information may be collected, collated and distributed to support requests for funding, advocacy, resource allocation and measuring outcomes. Please refer to the Personal Information Protection Act