Developmental Services Case Resolution Mechanism

To initiate the referral the following is required:

• Complete all relevant sections of the referral form outlined below.
• Upload a detailed service plan or plan of care. The plan must include a thorough outline of the presenting issues identified in SECTION 4. Any funding requests must be costed and outlined in the plan.
• Upload signed SCS consent forms.

SECTION 1 – REFERRAL INFORMATION

Service Provider Name:

SECTION 2 – CHILD/YOUTH AND FAMILY INFORMATION

Date of Birth

SECTION 3 – DEMOGRAPHIC INFORMATION

indicate parent name:

Indicate type of care agreement:

Language Preferred for services:

Language Preferred for correspondence:

SECTION 4 – PRIMARY PRESENTING ISSUES – A detailed description must be outlined in service/ plan of care

MENTAL HEALTH Diagnosis:

SECTION 5 - FINANCIAL INFORMATION

Upload Service Plan or Plan of Care

Drop files here or

Max. file size: 512 MB, Max. files: 3.

Download Consent Form

Please review and complete with the legal caregiver/ guardian and individual if over 16 years of age and then upload using the field below.

Case Resolution Referral Form

To initiate the referral the following is required:

SECTION 1 – REFERRAL INFORMATION

SECTION 2 – CHILD/YOUTH AND FAMILY INFORMATION

Primary Contact

Secondary Contact

SECTION 3 – DEMOGRAPHIC INFORMATION

SECTION 4 – PRIMARY PRESENTING ISSUES – A detailed description must be outlined in service/ plan of care

SECTION 5 - FINANCIAL INFORMATION

Section 6 - Consent