• Overnight Respite Form

    Thank you for your interest in overnight respite services at ErinoakKids! Registration is now open.
    • Eligibility 
    • Is this the first form you are submitting for overnight respite? We can accept only one form per child/per respite service.*

    • Not eligible

      Thank you. We can accept only one form per child/per respite service. If you have questions, please reach out to Respite Admin at 905-855-2690 ext. 2273.

    • Is this your child/loved one's first visit to our overnight respite program?*
    • Was your child's/loved one's last stay with us within the last 12 months?*

    • Not eligible

      Thank you for your interest in respite at ErinoakKids. Unfortunately, your child/loved one does not meet the criteria for this service. For questions, please reach out to Respite Admin at 905-855-2690 ext. 2273. For assistance coordinating appropriate in-home or community-based care, please visit Ontario Health atHome.

    • Does your child/loved one live at home with their parent/guardian/foster parent?*

    • Not eligible

      Thank you for your interest in respite at ErinoakKids. Unfortunately, your child/loved one does not meet the criteria for this service. For questions, please reach out to Respite Admin at 905-855-2690 ext. 2273. For assistance coordinating appropriate in-home or community-based care, please visit Ontario Health atHome.

    • Within the past 6 weeks has your child/loved one been admitted to hospital for concerns with mental health or escalated behaviour?*

    • Not eligible

      Thank you for your interest in respite at ErinoakKids. Unfortunately, your child/loved one does not meet the criteria for this service. For questions, please reach out to Respite Admin at 905-855-2690 ext. 2273. For assistance coordinating appropriate in-home or community-based care, please visit Ontario Health atHome.

    • Does your child/loved one have an antibiotic resistant organism such as MRSA, VRE, or c-difficile?*

    • Not eligible

      Thank you for your interest in respite at ErinoakKids. Unfortunately, your child/loved is not eligible at this time. Please contact Respite Admin at 905-855-2690 ext. 2273 to discuss next steps with a nurse.

    • Does your child/loved one use a ventilator for breathing?*

    • Not eligible

      Thank you for your interest in respite at ErinoakKids. Unfortunately, your child/loved one does not meet the criteria for this service. For questions, please reach out to Respite Admin at 905-855-2690 ext. 2273. For assistance coordinating appropriate in-home or community-based care, please visit Ontario Health atHome.

    • Does your child/loved one have an antibiotic resistant organism such as MRSA, VRE, or c-difficile?*

    • Not eligible

      Thank you for your interest in respite at ErinoakKids. Unfortunately, your child/loved is not eligible at this time. Please contact Respite Admin at 905-855-2690 ext. 2273 to discuss next steps with a nurse.

       

    • Additional Requirements 
    • Does your child/loved one have a MFTD (Medically Fragile Technologically Dependent) designation, complex medical needs, and/or equipment to support physical needs requiring nursing support?*
    • Does your child/loved one require supplemental oxygen?
    • Does your child/loved one have a tracheostomy or artificial airway?
    • Does your child/loved one currently use a safety enclosed bed at home? Please see pictures below for description.

    • Standard Respite Bed

       

       

    • Safety Enclosed Bed

       

    • Does your child/loved one have a MFTD (Medically Fragile Technologically Dependent) designation, complex medical needs, and/or equipment to support physical needs requiring nursing support?
    • Does your child/loved one demonstrate aggression towards others (e.g., kicking, biting, hitting, etc.) or themselves (e.g., head hitting, self-biting, etc.) on a daily basis?
    • Does your child/loved one demonstrate aggression towards others (e.g., kicking, biting, hitting, etc.) or themselves (e.g., head hitting, self-biting, etc.) on a daily basis?
    • Does your child/loved one ever try to leave the house or building without notice?
    • Does your child/loved one ever hit, break, or damage items in their environment (on purpose or by accident)?
    • Does your child/loved one ever hit, break, or damage items in their environment (on purpose or by accident)?
    • Date Selection 

    • Note:

      Each week you click will move to your 'Weeks Selected' in order from highest preference to lowest preference. If you want to change the order, click on the week under 'Weeks Selected' and it will go back to 'Options Available'.

    • Note:

      Each week you click will move to your 'Weeks Selected' in order from highest preference to lowest preference. If you want to change the order, click on the week under 'Weeks Selected' and it will go back to 'Options Available'.

    • Child/Loved One Information 
    • Date of Birth*
       - -
    • Primary Contact Information (This is the only person who will be contacted with service information and updates) 
    • Format: (000) 000-0000.

    • Interpreter required?
    • Consent 

    • This information is being submitted with the knowledge and consent of the parents/legal guardians. By providing the contact information with the form(s), you consent to receiving information about your service at ErinoakKids by email, SMS/Text and other electronic means.

    • Consent Received:*

    • If No, ErinoakKids will not process this referral.

    • ErinoakKids also shares information on new service offerings, fundraising initiatives, free events offered at ErinoakKids and surveys by email, post, SMS/text and other electronic means. ErinoakKids will always treat your personal details with the utmost care and will not share or sell your personal information. You may unsubscribe from receiving communications from ErinoakKids at any time. We are committed to keeping your information safe and confidential. We follow the rules set out in law about collecting, using and disclosing your personal information. For more information, please review our privacy policies publicly posted at https://www.erinoakkids.ca/privacy.

    • Consent Received:*
    • Should be Empty: