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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

DD slash MM slash YYYY

Completed with Parents
Do you have consent to refer this individual?

1.3 - The Child/Youth/Family Referred would like to:(Required)

Section 2 - Information about Child/Youth

2.1 - General Information

MM slash DD slash YYYY
Interpreter Required:
The child/youth will accept services in the following language
2.2 - This child/youth has a confirmed diagnosis of:(Required)
Details for Developmental Disability Diagnosis
Details for New Diagnosis
2.3 - How the Child/Youth communicates

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

Check all that applies
Risk of Harm
Medical Health
Mental Health
Physical Health
Police Involvement/At risk with legal system?

2.5 - Information about Education

Grade Level (If Applicable)
This person is a Youth 14 to 18 years:
School Program
Support Level
Are there challenges in school?

Section 3 - Information on Parents/Caregivers

3.1 - Primary Contact Person

Select Preferred Method of Communication(Required)
Are you the person we should communicate with?
Parent/caregiver Risk Factors
Is there a secondary contact?

3.1 - Secondary Contact

Select Preferred Method of Communication(Required)
Are you the person we should communicate with?
Parent/Caregiver Risk Factors

3.2 - Family Living Situation

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

Section 4 - Financial Supports

Will be completed by a case manager if applicable
Will be completed by a case manager if applicable
Will be completed by a case manager if applicable
Will be completed by a case manager if applicable

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

Will be completed by a case manager if applicable
Will be completed by a case manager if applicable
Other private/public resources?

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

Service Coordination Support/Soutien (SCS)

507 - 1400 boul. St. Laurent Blvd.
Ottawa, ON, K1K 4H4
Main office phone number/Numéro de téléphone du bureau principal: 613-748-1788
Fax: 613-748-1018
admin@scsonline.ca
This website is using a WordPress Theme that meets the Web Content Accessibility Guidelines (WCAG) 2.0 Level AA

We have moved!

Please note our new address: 507 – 1400 St. Laurent Boulevard, Ottawa, ON K1K 4H4

SCS Website Accessibility

Our website now uses accessiBe, a tool that makes our website accessible to people with motor impairments, visual impairment, cognitive disabilities, and more.

You can click on the button in the lower left corner of our website to activate accessiBe:

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Service Coordination Support (SCS)
  • Home
  • About us
    • Mission / Vision
    • Board of Directors
    • Annual Reports
    • Job Opportunities
    • Feedback & Policies
    • FAQs
  • Services
    • SCS Roadmap
    • Children’s Case Management
    • DSOER
    • Adult Case Management
    • respiteservices.com in Ottawa
    • Coordinated Service Planning for Children and Youth
    • Residential and Community Services (RCS)
  • Intake
    • Case Management (Intake)
    • Application DSOER
  • Resources
    • Community Options for Adults
    • Instructional Videos
    • List of resources
    • My Search Tool
    • Newsletter
    • Transition Planning Tips Sheets
  • What’s New
  • Contact us
  • Language
    • English
    • Français