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?

    Completed with Parents:
    Consent to Refer:

    1.2. THE CHILD/YOUTH/FAMILY I AM REFERRING WOULD LIKE TO:


    SECTION 2 - INFORMATION ABOUT THE CHILD/YOUTH:


    2.1. GENERAL INFORMATION

    Date of Birth:
    Interpreter required:
    The child/youth would like to receive services in:

    2.2. THIS CHILD/YOUTH HAS A CONFIRMED DIAGNOSIS OF:

    The child/youth has the following Child and Adolescent Needs and Strength Assessment (CANS):


    2.3. HOW THE CHILD/YOUTH COMMUNICATES (check all that apply):


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

    Risk of harm to self or others?
    Medical Health:

    Mental Health:

    Physical Health:

    Other Risks:

    Police involvement/ At risk with legal system?

    2.5. INFORMATION ABOUT THE CHILD/YOUTH’S EDUCATION/ SCHOOL

    This person is a Youth 14 to 18 years:
    If YES, has the school engaged or started transition planning with he/she?
    School program:

    Support level:

    Are there challenges at school?

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


    3.1. Primary Contact Person

    Select preferred method of communication:


    Is there a secondary contact:

    3.2. Secondary Contact Person

    Select preferred method of communication:


    3.3. Family Living Situation

    Family and Living Situation:


    SECTION 4 - Service Request

    I am looking for: