General Referral Form

  • General 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.

    • 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

    • Additional Consent 
      • Where multiple organizations may provide a similar service, the named parent/legal guardian must provide informed consent for ErinoakKids to disclose Personal Health Information (i.e., name, date of birth, diagnosis) to our Infant and Child Development Services community partner for the purpose of ensuring that the referral is directed to the best organization to meet the child's need and avoid duplication of services.
    • Consent Received*
    • 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 (not available for all services).


    • 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?*
    • Does the child/youth currently attend daycare or school?

    • Note*: This information can help your clinician coordinate any appointments/information with these providers (once discussed and consent has been provided).

    • Medical Information 
    • Allergies*
    • EpiPen Required?*
    • Has the child/youth received a diagnosis, or is a diagnosis suspected?*
    • ErinoakKids Services Requested 

    • Please read prior to selecting services:

      • Services are provided for children with physical or developmental disabilities, impairments with communication, hearing or vision. Family must live in the catchment area of service. Please visit www.erinoakkids.ca/All-Services for detailed eligibility criteria for services at ErinoakKids.
      • Please select all services that are being requested. For each service requested, additional information may be required to complete the referral. Please ensure all required fields are completed and any required documents are uploaded with this referral submission to avoid delays.
      • If you do not see the "Submit" button, it means you may be ineligible for one or more of the services you selected. Please uncheck any service where an ineligibility message appears. You can proceed with submitting the referral for services you are eligible for. 

    • Note*: Please carefully review the referral criteria for ADRS prior to completing the referral form: erinoakkids.ca/ADRS. If your child is preschool aged and has not seen a Speech-Language Pathologist before, a referral to Preschool Speech and Language services may be more appropriate. Please check the Preschool Speech and Language box further down the referral form. 

    • Please indicate the total number of picture symbols/photographs, gestures (i.e., pointing, pretending to eat to request food), signs, word approximations (i.e., "ma" for "more") and/or words (may be a combination of these) that the child/youth uses to communicate intentionally:
    • Note*: Please carefully review the referral criteria for the Infant Hearing Program (IHP) Audiology Services prior to completing the referral form: erinoakkids.ca/Audiology.
      An Audiological Assessment or other supporting documentation (e.g., confirmation of permanent hearing loss) is required to be uploaded with this referral submission.
    • Does the child/youth have a confirmed or suspected permanent hearing loss or are they at risk of a permanent hearing loss?*
    • Not Eligible

      An Audiological Assessment indicating a permanent hearing loss is required to access IHP Audiology Services. Please contact an Audiologist in your community to complete an assessment: ErinoakKids - Audiologist in our region. You will not be able to proceed with your submission for this service referral.

    • Is the child/youth wearing hearing aids or cochlear implants?*
    • Does the child/youth have a prescription for a hearing aid?*
    • Autism Services
      This referral form cannot be used to request Autism Services. For more information about the services and supports ErinoakKids offers to children and youth with Autism and their families, please visit our website: erinoakkids.ca/Autism
      To refer for an Autism Diagnostic Assessment, please select 'Medical Clinics' below. 
    • Note*: Please carefully review the referral criteria for BLV Services prior to completing the referral form: erinoakkids.ca/BLV

      An Ophthalmologist Assessment is recommended to be uploaded with this referral submission.

    • Has a visual impairment been diagnosed or is it strongly suspected?*
    • Not Eligible

      A diagnosis or strong suspicion of a visual impairment is required to access Blind-Low Vision Early Intervention Program Services. If the child has not yet been assessed, please consult an opthamologist in your community. You may also explore additional supports through External Vision Resources. You will not be able to proceed with your submission for this service referral.

    • Coordinated Service Planning
      This referral form cannot be used to request Coordinated Service Planning. For more information about ErinoakKids community collaboration for planning and coordination of services, please visit our website: erinoakkids.ca/CSP
    • Early Childhood Resource Services
      This referral form cannot be used to request Early Childhood Resource Services. For more information about ErinoakKids collaboration with child care centres, please visit our website: erinoakkids.ca/ECRS
    • Family Support Services (Recreational Therapy, Service Navigation, Social Work, Transitions Services)  
      These additional services are available to existing clients through an internal referral process initiated by an ErinoakKids clinician. For more information about these services, please visit our website: erinoakkids.ca/Familysupports
    • Note*: Please carefully review the referral criteria for FASD Services prior to completing the referral form: erinoakkids.ca/FASD. FASD services are only available to residents of Peel. ErinoakKids does not provide a diagnostic assessment.
       
      A diagnostic report is recommended to be uploaded with this referral, if available.

    • Note*: Please carefully review the referral criteria for Medical Services prior to completing the referal form: erinoakkids.ca/Medicalclinics. Please note we do not accept referrals for Attention Deficit Hyperactivity Disorder (ADHD), Learning Disability (LD), Developmental Coordination Disorder (DCD), Psychoeducational Assesement, Acquired Brain Injury (ABI) or second opinion for ASD diagnosis. 

      Referrals for Medical Clinics must originate from a Physician. Families/caregivers may submit this form, but they must upload the Physician's referral document with all required supporting materials. 

    • Does the child/youth exhibit repetitive behaviours or restricted interests, and are there concerns regarding social communication?*
    • Not Eligible

      Based on the information provided in your referral form, this child/youth does not meet the eligibility criteria for an ASD diagnostic assessment at this time. You will not be able to proceed with your submission for this service. If there is additional relevant information, you may submit a new referral or contact 905-855-2690 ext. 1 for guidance on alternative supports.

    • Note*: Please carefully review the referral criteria for OT Services prior to completing the referral form: erinoakkids.ca/OT 
    • Note*: Please carefully review the referral criteria for PT Services prior to completing the referral form: erinoakkids.ca/PT
    • Note*: Please carefully review the referral criteria for PT Services prior to completing the referral form: erinoakkids.ca/PT
    • Note*: Please carefully review the referral criteria for PSL Services prior to completing the referral form: erinoakkids.ca/PSL
    • Please complete the Communication Checkup Tool (CCT) prior to submitting a preschool speech and language referral. Upon completion of the CCT, you will be directed back to this referral form. The CCT results can be uploaded as part of your referral submission.
    • Respite Services
      This referral form cannot be used to request Respite Services. For more information about how Respite at ErinoakKids provides short-term breaks for caregivers of children, youth or young adults with complex medical or complex behavioural needs, please visit our website: erinoakkids.ca/Respite
    • School Based Rehabilitation Services (SBRS)
      This referral form cannot be used to request School Based Rehabilitation Services (SBRS). For more information about ErinoakKids SBRS program and how to submit a referral, please visit our website: erinoakkids.ca/SBRS
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    • Additional Referral Requirements 
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Referral Source Information 
    • Referral Source*
    • Submit 
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