Urgent Response Services Referral Form

Ontario Autism Program (OAP) Urgent Response Services (URS) 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, 8:00 am to 5:00 pm.

*Important* - This is not a crisis line. If this is an emergency, please call 911.

General Consent
- This request is being submitted with the knowledge and consent of the named parents/legal guardians, in accordance with the ErinoakKids Privacy Policy available at erinoakkids.ca/privacy.
- Child/youth/parent/legal guardian grant consent to have ErinoakKids enter referral information into its database.
Consent Received*

YesNo
Consent must be received to submit this referral

Additional Information Required for OAP Urgent Response Services
Referral Date *

DayMonthYear
First Contact Date (Offered) *

DayMonthYear
First Contact MUST be on or after the Date of Referral.
Date Level 1 Eligibility Screening Completed *

DayMonthYear
Outcome of Level 1 Eligibility Screening*
Level 1 Eligibilty MUST be on or after the First Contact Date
Date Level 2 Eligibility Screening Completed (if applicable)*

DayMonthYear
Outcome of Level 2 Eligibility Screening*
Level 2 Eligibility Screening MUST be on or after the Date of Level 1 Eligibilty Screening.
Consent provided by family for EOK to contact CRT to obtain Ministry Reference #*

YesNo
High Risk Factor Identified During Screening*
Does the child/family meet the eligibility criteria for Crisis?*
Does the child/family meet the eligibility criteria for Crisis?
Was the child/family referred for other services? (Choose all that apply)*

Service NavigationSocial WorkCoordinated Service PlanningOAP Foundational Family ServicesNone IdentifiedOther
Please specify*

Ontario Autism Program (OAP) Urgent Response Services (URS) Referral Form