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*

    • Consent must be received to submit this referral

    • Ontario Autism Program (OAP) Registration Information 

    • Note*: Please carefully review the eligibility criteria for URS prior to completing the referral form

    • Is the child/youth currently registered with the Ontario Autism Program (OAP)?*

    • Not Eligible

      If your child/youth has received an autism diagnosis, please visit the OAP website or call the Central Resource Team at 1-888-444-4530 to register for the Ontario Autism Program.

    • Child/Youth Information 
    • Date of Birth*
       - -
    • Primary Contact (This is the first person who will be contacted with service information and updates)  
    • Relationship to child/youth*
    • Format: (000) 000-0000.

    • Note*: If a cell phone number is provided, you may be eligible to receive appointment notifications and reminders by text messaging.


    • Address Information*
    • Is the Primary Contact the legal guardian? If No, please complete the required fields.*
    • Format: (000) 000-0000.
    • Optional Secondary Contact (This person will be contacted only if the Primary Contact is unavailable) 
    • Would you like to add a Secondary Contact?*
    • Relationship to child/youth*
    • Format: (000) 000-0000.

    • Address Information*
    • Additional Child/Youth Information 
    • Are Interpreter Services required?*
    • Medical Information 
    • Allergies*
    • EpiPen Required?*
    • Is the child/youth involved with any professionals or services in the community (either active or waiting for services)?*
    • Additional diagnoses beyond Autism Spectrum Disorder (ASD)?*
    • Referral Source 
    • Referral Source*
    • Contracted URS Partner Agency 
    • Are you completing this referral as a Contracted Partner Agency?*
    • Additional Information Required for OAP Urgent Response Services 

    • Note*: This section can only be completed by staff of DCAFS, ROCK & Sunbeam

    • Referral Date *
       - -
    • First Contact Date (Offered) *
       - -

    • First Contact MUST be on or after the Date of Referral.

    • Date Level 1 Eligibility Screening Completed *
       - -

    • Level 1 Eligibilty MUST be on or after the First Contact Date

    • Date Level 2 Eligibility Screening Completed (if applicable)*
       - -

    • 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 #*
    • Was the child/family referred for other services? (Choose all that apply)*
    • Submit 
    • Should be Empty: