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- INFORMATION ABOUT THE REFERRAL SOURCE

1.1. TO : SERVICE COORDINATION FOR PEOPLE WITH DEVELOPMENTAL DISABILITIES (SCS)

Who is making this referral?

Name:
Completed with Parents:
YesNo
Agency Name:
Consent to Refer:
VerbalWritten
Contact Number:
Email address:
1.2. THE CHILD/YOUTH/FAMILY I AM REFERRING WOULD LIKE TO:

a) I would like to register with SCS but do not wish to be contacted by a case managerb) I would like to register with SCS and receive e-mail notifications of community events and/or SCS events and initiativesc) I would like to register with SCS to receive assistance from a Case Manager to access community resources and to receive e-mail notifications of community events, including SCS events and initiatives

I understand that regardless of the option chosen above I can, at any point, call, e-mail or visit SCS for information or support. Initial here:

SECTION 2 - INFORMATION ABOUT THE CHILD/YOUTH:

2.1. GENERAL INFORMATION

Child’s first name:
Last name:
Date of Birth:
*Gender:
Address:
Postal Code:
Home Phone #:
Language spoken at home:
Interpreter required:
YesNo
The child/youth would like to receive services in:
2.2. THIS CHILD/YOUTH HAS A CONFIRMED DIAGNOSIS OF:

Autism
Details if applicable:
Developmental Disability
Details if applicable:
Other Diagnosis
Details if applicable:

The child/youth has the following Child and Adolescent Needs and Strength Assessment (CANS):
Intake CANSMedically Fragile (MCSN) CANSAutism Spectrum Disorder CANSMental Health CANSNoneUnknown

2.3. HOW THE CHILD/YOUTH COMMUNICATES (check all that apply):
Full sentencesSome wordsGesturesAugmented CommunicationSign languageNon VerbalVocalizeOther

2.4. INFORMATION ABOUT THE CHILD/YOUTH’S HEALTH, WELLNESS AND SAFETY

Behavioural concerns:
Risk of harm to self or others?
YesNo
Medical Health:

Other or additional medical health challenge(s):

Mental Health:

Other or additional mental health challenge(s):

Physical Health:

Other or additional physical health challenge(s):

Other Risks:

Police involvement/ At risk with legal system?
YesNo
2.5. INFORMATION ABOUT THE CHILD/YOUTH’S EDUCATION/ SCHOOL

Name of Preschool/School:
Grade level (if applicable):
This person is a Youth 14 to 18 years:
YesNo
If YES, has the school engaged or started transition planning with he/she?
YesNoI don’t know
School program:

If you selected other, please provide more information below:
Support level:

If you selected other, please provide more information below:
Are there challenges at school?
SuspensionsExpulsionsNon-Attendance Record by child / youth
Comments regarding education (Please explain):

SECTION 3 - INFORMATION ABOUT THE CHILD’S PARENT /CAREGIVER

3.1. Primary Contact Person
Relationship to the child:

First Name:
Last Name:
Address: (if different from above)
Postal Code:

Select preferred method of communication:

Home Phone
Email
Work Phone
Cell Phone
Is there a secondary contact:
YesNoI don’t know

3.2. Secondary Contact Person
Relationship to the child:

First Name:
Last Name:
Address: (if different from above)
Postal Code:

Select preferred method of communication:

Home Phone
Email
Work Phone
Cell Phone

3.3. Family Living Situation

Family and Living Situation:
Change in marital statusCAS involvement/Temporary Care Agreement dischargeFinancial breakdownHomeless/shelterOther sibling(s) requiring additional supportRisk of housing loss

Other details: Who lives in your home? What is your support network like? Financial Situation? What additional demands affect your family life?

SECTION 4 - Service Request

I am looking for:

Respite and/or a special needs worker
Parent support groups (focus and/or support groups)
Social skill groups (building social networks)
Activities to promote social life (community participation, recreation and leisure)
Environmental, adaptive equipment supports
Legal supports
Health supports (medical, nutrition, physical health, exercise, therapies, mental health, etc.)
Behavioural supports
Supports within the educational system (navigating the school system, preschool, day care, after school program, post-secondary education etc.)
Transition Planning (planning post-graduation and skill building opportunities)
Volunteer opportunities
Training opportunities, educational workshops, etc.
Life skill building opportunities (Preparing for independence, use of transportation, shopping, budgeting, Self-care, etc.)