School Based Rehabilitation Services (SBRS) Referral Form

School Based Rehabilitation Services (SBRS) Referral Form
Please complete all required fields below (marked with *). If you have any questions or experience any issues, you may contact the ErinoakKids Intake team at 905-855-2690 (toll free 1-877-374-6625) and press 1 for support, from Monday-Friday, 8:00am to 5:00pm.

*Important* - This form must be completed by the School Team

Referral Source and Principal/Designate Authorization
School Board*
Referrals must be associated with a school in our region
Referral Code*
You have entered an invalid referral code. If you do not know your referral code, please contact your ErinoakKids school clinician.
Your First Name*
Your Last name*
Your Role*
Your Email*

Confirmation Email
School Name*
Complete School Address*

Street Address

Unit Number (if applicable)

CityProvince

Postal Code
School Phone Number*
Extension (if applicable)
Does the principal or designate support referral for services?*

YesNo
The principal or designate must support referral to continue
First Name of principal or designate*
Last Name of principal or designate*

General Consent
- This request is being submitted with the knowledge and consent of named student/parent/legal guardian, in accordance with the ErinoakKids Privacy Policy available at erinoakkids.ca/privacy.
- Student/parent/legal guardian grant consent to have ErinoakKids enter referral information into its database.
- Student/parent/legal guardian acknowledge that ErinoakKids will exchange and share information with the school and school board, and the school that the student is attending is within ErinoakKids catchment area, and that the school board and the school will share information back with ErinoakKids.
Consent Received*

YesNo
Consent must be received to submit this referral

Student Information
First Name*
Last Name*
Date of Birth*

DayMonthYear
Gender*
Address*

Street Address

Unit Number (if applicable)

CityProvince

Postal Code

Primary Contact (This is the first person who will be contacted with service information and updates)
First Name*
Last Name*
Relationship to Student*

MotherFatherOther
Please specify*
Phone Number *
Please Specify Type*
Extension (if applicable)
Note* - If a cell phone number is provided, you may be eligible to receive appointment notifications and reminders by text messaging (not available for all services).
Email Address

Confirmation Email
Address Information*

Same as StudentDifferent from Student
Address*

Street Address

Unit Number (if applicaable)

CityProvince

Postal Code
Is the Primary Contact the legal guardian? If No, please complete the required fields.*

YesNo
Agency Name*
Caseworker Name*
Caseworker Phone Number*
Extension (if applicable)

Optional Secondary Contact (This person will be contacted only if the Primary Contact is unavailable)
Would you like to add a Secondary Contact?*

YesNo
First Name*
Last Name*
Relationship to Student*

MotherFatherOther
Please specify*
Phone Number*
Please Specify Type*
Extension (if applicable)
Email Address

Confirmation Email
Address Information*

Same as StudentSame as Primary ContactDifferent from both
Address*

Street Address

Unit Number (if applicabale)

CityProvince

Postal Code

Additional Student Information
How is the student currently attending school?*

In-personVirtuallyOther
Please Specify*
Primary language spoken at home*
Please specify other language*
Are interpreter services required?*

YesNoUnsure
If yes, state language/ASL*

Medical Information
Allergies*

YesNo
If yes, specify allergy*
EpiPen Required?*

YesNoUnsure
If yes, specify the EpiPen allergy*

Service(s) Requested and Priority of Services
Note* - This section is mandatory. Select one or more services to continue.
Occupational Therapy Services
Date of SBRS OT consultation:*

DayMonthYear
SBRS OT First Name: *
SBRS OT Last Name:*
Describe at least one concern under any of the criteria below

Refer to Priority Rating Tool for criteria (To proceed, you must select at least one checkbox if the referral type is Priority or Urgent)*

STANDARD ReferralPRIORITY ReferralURGENT Referral
Able to attend school but has physical accessibility needs within the school environment (e.g. toileting, positioning) requiring equipment assessmentUnable to attend school due to self regulation concerns
Safety assessment required due to significant physical needs or change in medical status for mobility equipment, lifts/transfers, toileting and positioning (e.g. post surgical, prolonged hospitalization).
Physiotherapy Services
Select at least one concern under any of the criteria below:*

Safety assessment regarding access to school environment (e.g. stairs, playground, participation in physical education class (consultation for Grade 1 students and up))Safety/equipment assessment (e.g. walkers, standing frame)

Refer to Priority Rating Tool for criteria (To proceed, you must select at least one checkbox if the referral type is Priority or Urgent)*

STANDARD ReferralPRIORITY ReferralURGENT Referral
Requires new equipment to support physical needsAble to attend school but has physical accessibility needs within the school environment (e.g. stander, walker) requiring equipment assessment
Mobility status or physical needs indicates an immediate safety riskSafety assessment due to significant physical needs or change in medical status for mobility equipment, lifts and transfers (eg post-surgical, prolonged hospitalization)
Speech Language Pathology Services
School Board SLP First Name*
School Board SLP Last Name*
School Board SLP Phone Number *
Extension (if applicable)
School Board SLP Email*

Confirmation Email
Reason for Referral

For detailed information on eligibility and prioritization, please refer to the Clinical Guidelines Document and/or watch the following videos
1. Speech Prioritization
2. Eligibility
Articulation
Severe (6 or more sound errors)Moderate (3-5 sound errors)"r" sounds (must be 7 and older if only sound error)Interdental/Frontal Lisp (must be age 7 and older if only sound error)Lateral Distortion/Lisp
Phonology
Moderate: 2 or more overdue phonological processes by age expectationSevere: 3 or more overdue phonological processes by age expectation
Motor Speech
MildModerateSevere
Stuttering - Risk of persistency/severity
MildModerateSevere
Voice/Resonance - Moderate to severe difficulties (ENT or Cleft Lip Palate report must be received prior to Initial Assessment)
Moderate to severe difficulties
Description of concerns*
Please provide detailed concerns
Refer to Priority Rating Tool for criteria (To proceed, you must select at least one checkbox if the referral type is Priority or Urgent)*

STANDARD ReferralPRIORITY ReferralURGENT Referral
New referrals for students under 8 years of age with severe phonology or severe motor speech, and/or moderate/severe fluency; Secondary school students post-frenectomy; post-recent acquired brain injury (ABI)
Post -operative referrals requiring urgent speech intervention such as cleft palate repairs; vocal cord repair
STANDARD Referral
PRIORITY Referral
URGENT Referral
OT
PT
SLP
Refer to Priority Rating Tool for criteria

PRIORITY Referral
Refer to Priority Rating Tool for criteria

URGENT Referral
Additional Information
Hearing

Identified hearing lossUses hearing technology (e.g. cochlear implants, FM System, hearing aides, etc.)
Language Development

Delayed/DisorderedWithin Normal Limits (WNL)Not Assessed
Uses Augmentative Communication
Is the student receiving intervention for language difficulties from the School Board SLP?*

YesNo
If yes, what kind of intervention is the student receiving?*


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Comments and Submit
Please provide any additional comments
School to send copies to:

Ontario Student RecordStudent/Parent/GuardianOther
Please specify:*
Last Name,First Name
None Provided
Please verify that you are human*
Should be Empty: