Registration Form - Service Coordination Support (SCS)

CHILDREN’S CASE MANAGEMENT - REFERRAL FORM

In order to register with Service Coordination Support (SCS) for people with developmental disabilities the intake worker will need to review supporting documentation to confirm your (the applicant’s) eligibility. As a central point of access, we provide information and facilitate access to services and supports for children and youth (0 to 18) with a developmental disability and Autism Spectrum Disorder (ASD) in the Ottawa area. In order for us to proceed with the registration, we require a psychological assessment (or any other document) confirming the diagnosis of a developmental disability and/or Autism Spectrum Disorder. As well, we require consent to allow us to collect, use or disclose information for the purpose of creating and maintaining your service record.

If you are having difficulty filling this form, please send us an email at childrensintake@scsonline.ca

Section 1 - Referral Information

1.1 - Date of Referral(Required)

DD slash MM slash YYYY

1.2 - Who is making this referral?(Required)

Name(Required)

Agency Name

Contact Number(Required)

Email Address(Required)

Completed with Parents

Yes

Do you have consent to refer this individual?

Yes

1.3 Assistance From a Case Manager(Required)

I confirm that I would like to register with SCS and receive assistance from a Case Manager to help me identify goals and develop a support plan.

Section 2 - Information about Child/Youth

2.1 - General Information

Child's First Name(Required)

Last Name(Required)

Date of Birth

MM slash DD slash YYYY

Gender

Address

Home Phone #(Required)

Postal Code(Required)

Interpreter Required:

Yes

Language spoken at home:

The child/youth's preferred language for communication is:

The child/youth will accept services in the following language

English

French

2.2 - This child/youth has a confirmed diagnosis of:(Required)

Autism

Developmental Disability

Other Diagnosis

New Diagnosis

Details for Autism Diagnosis (if applicable):

Details for Developmental Disability Diagnosis

Angelman's Syndrome

DD (Mild/Leger 317)

DD (Moderate 318.0)

DD (Severe 318.1)

DD (Profound 318.2)

DD (Severity Unspecified 319)

DD (Severity Unconfirmed)

Down Syndrome

Fragile X

Global Developmental Delay

Prader Willi Syndrome

Trisomy 21

Williams Syndrome

Further Details for Developmental Disability Diagnosis (if applicable):

Details for New Diagnosis

Developmental Disability

Autism Spectrum Disorder

2.3 - How the Child/Youth communicates

Full Sentences

Some words

Gestures

Augmented communication

Sign Languages

Non verbal

Pictures (PECS)

Vocalize

Other

2.4 - Information about the child/youth's health, wellness and safety

Check all that applies

Behavioural Concerns

Medical Health

Mental Health

Physical Health

Risk of Harm

Self

Others

Comments Regarding Behavioural Concerns

Medical Health

AIDS/HIV

Allergies

Cancer

Cardiac

Diabetes

Epilepsy

Respiratory

Seizure Disorder

Frequent Hospitalization

Other

Comments Regarding Medical Health

Mental Health

ADD (Attention Deficit Disorder)

ADHD (Attention Deficit Hyperactivity Disorder)

Anxiety

Bipolar Disorder

Generalized Anxiety Disorder

Major Depressive Disorder

Mood Disorder

ODD (Oppositional Defiance Disorder)

Obessive Compulsive Disorder

Obessive Compulsive Personality Disorder

Sexualized Behaviours

Personality Disorder NOS

Pica

Post-Traumatic Stress Disorder

Psychotic Disorder

Schizoaffective Disorder

Schizophrenia

Tourette's Syndrome

Other

Comments Regarding Mental Health

Physical Health

Blind/Visually Impared

Cerebral Palsy

Fetal Alcohol Spectrum Disorder

Head Injury/ABI

Hearing Impaired

Hydrocephalus

Myotonic Distrophy

Paraplegic

Quadriplegic

Speech Delay

Spina Bifida

Tuberous Sclerosis

Other

Comments Regarding Physical Health

Police Involvement/At risk with legal system?

Yes

Additional Information

2.5 - Information about Education

Name of Preschool/School

Grade Level (If Applicable)

Kindergarten (JK/SK)

Primary (Grades 1-3)

Junior (Grades 4-6)

Intermediate (Grade 7-8)

Senior/Secondary (Grades 9-12)

This person is a Youth 14 to 18 years:

Yes

I don't know

Non applicable

School Program

Full Time

Part Time

Fully Integrated

Special Needs Program

Autism Program

Other

Other:

Support Level

Independent

Need some support

Modified Program

Resource Classroom

Other

Are there challenges in school?

Suspensions

Expulsions

Non-Attendance Record by child/youth

Comments Regarding Education (Please Explain)

Section 3 - Information on Parents/Caregivers

3.1 - Primary Contact Person

Relationship to Child

First Name(Required)

Last Name(Required)

Address (if different from above)(Required)

Postal Code(Required)

Select Preferred Method of Communication(Required)

Home Phone

Work Phone

Cell Phone

Other

Home Phone #:(Required)

Email Address:(Required)

Work Phone #:(Required)

Cell Phone #:(Required)

Other:(Required)

Are you the person we should communicate with?

Yes

Parent/caregiver Risk Factors

Aging Caregiver

Medical Condition

Mental Health Concerns

Diagnosis of Developmental Disability

Language Barrier

Single Parent

Is there a secondary contact?

Yes

3.1 - Secondary Contact

Relationship to Child

First Name(Required)

Last Name(Required)

Address (if different from above)

Postal Code

Select Preferred Method of Communication(Required)

Home Phone

Work Phone

Cell Phone

Other

Home Phone #:(Required)

Email Address:(Required)

Work Phone #:(Required)

Cell Phone #:(Required)

Other:(Required)

Are you the person we should communicate with?

Yes

Parent/Caregiver Risk Factors

Aging Caregiver

Medical Conditions

Mental Health Concerns

Diagnosis of Developmental Disability

Language Barrier

Single Parent

3.2 - Family Living Situation

Family and Living Situation

Change in Marital Status

Financial Breakdown

Homeless/shelter

Risk of Housing loss

Other sibling(s) require additional support

CAS Involvement

Other Details:

Who lives in your home? What is your support network like? Financial situation? What additional demands affect your family life?

Section 4 - Financial Supports

Disability tax credits/arrears

Year of Application

Special Services at Home (SSAH)

Year of SSAH application

SSAH Annual Amount

Will be completed by a case manager if applicable

Special Agreements Officer Names (SAO)

Will be completed by a case manager if applicable

Ontario Autism Program

Year of Ontario Autism Program Application

Autism Spectrum Disorder Initiative (SCS)

Year of Autism Spectrum Disorder Initiative (SCS) Application

Autism Spectrum Disorder Initiative (SCS) Amount

Will be completed by a case manager if applicable

CCAC Enhanced Respite

Year of Enhanced Respite Application

CACC Enhanced Respite Amount

Will be completed by a case manager if applicable

Easter Seals Incontinence Grant

Year of Easter Seals Incontinence Grant

4.1 - Financial Supports, for household income below $63,000

Assistance for Children with Severe Disabilities (ACSD)

Year of Assistance for Children with Severe Disabilities (ACSD) application

Assistance for Children with Severe Disabilities (ACSD) monthly amount

Will be completed by a case manager if applicable

ACSD Special Agreements Officer Names (SAO)

Will be completed by a case manager if applicable

Other private/public resources?

Yes

Additional information about financial supports

Section 5 - Service Request

How can we best support you? (What type of resources are you looking for at this time? What are you hoping a case manager can assist you with?)

I need a case manager to help me coordinate community resources such as:(Required)

Skills development or education programs

Social and recreational programs

Child care programs

Support workers or respite programs

Volunteer or work opportunities

Support Groups

Financial Programs

Housing Services

Transportation Services

Specialized services, such as counselling, behaviour management, medical, therapy, equipment...

Coordinate meetings with other service providers

Other

Other:

Name

This field is for validation purposes and should be left unchanged.