• Enhanced Day Respite Form

    Thank you for your interest in enhanced day respite services at ErinoakKids! Registration is now open.
    • Eligibility 
    • Is this the first form you are submitting for enhanced day 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 respite program?*

    • 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.

    • Does your family live in the region of Halton or Peel?*

    • 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 one 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 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.

    • 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 one is not eligible at this time. Please contact Respite Admin at 905-855-2690 ext. 2273 to discuss next steps with a nurse.

    • 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.

    • 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.

    • 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 have challenging behaviour needs, autism, or other developmental disabilities that make it difficult to access community based programs AND require medication administration or nursing support during their stay?*

    • 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 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 require more than one person to ensure their safety and participation at home or in school?*

    • 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 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 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 challenging behaviour needs, autism, or other developmental disabilities that make it difficult to access community based programs AND require medication administration or nursing support during their stay?*

    • 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 require more than one person to ensure their safety and participation at home or in school?*

    • 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 require supplemental oxygen?*
    • Does your child/loved one require supplemental oxygen?*
    • Does your child/loved one have a tracheostomy or artificial airway?*
    • 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 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 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 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)?*
    • How will you be paying for your respite stay?*
    • How will you be paying for your respite stay?*
    • Date Selection 

    • Enhanced day respite services are available in the following option:

      1. Extended adult day (9:30am - 6:30pm) on Wednesdays for 6 weeks (Brampton site only)

    • Note:

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

    • Enhanced adult day respite services are available in the following option:

      1. Extended day (9:30am - 6:30pm) on Wednesdays for 6 weeks (Brampton site only)

    • Note:

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

    • Date Selection 

    • Enhanced day respite services are available in the following options:

      1. Wednesdays from 9:30am - 6:30pm: one weekday over 6 weeks (Brampton site only)

      2. Saturday & Sunday from 9:00am - 3:00pm: two weekend days over 3 weeks (Brampton site only)

    • Note:

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

    • Enhanced day respite services are available in the following options:

      1. Wednesdays from 9:30am - 6:30pm: one weekday over 6 weeks (Brampton site only)

      2. Saturday & Sunday from 9:00am - 3:00pm: two weekend days over 2 weeks (Brampton site only)

    • Note:

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

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

    • Address*
    • Is the primary contact the legal guardian? If No, please complete the required fields.*
    • Format: (000) 000-0000.
    • Who does your child/loved one live with?*
    • Interpreter required?*
    • Medical Information 
    • Diagnosis*
    • Does your child/loved one have allergies?*
    • Is an EpiPen 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: