KidsAbility Online Referral Form

Reason for Contacting KidsAbility (be as detailed as possible):

Please provide details about the individual that is being referred to our programs.

Child Care or School Information

Parent or Caregiver Information

If there is a preferred time to contact, please specify.

Parent or Caregiver Information

Additional Information

Collection and Sharing Consent

Client/Family agree with this referral including the collection and sharing of information for the purposes of processing referral

If you have any questions or need assistance completing this referral, please call (519) 886-8886 ext. 1214. IF YOU WISH TO INCLUDE ANY ADDITIONAL DOCUMENTATION TO SUPPORT THIS REFERRAL, PLEASE FAX TO 519-886-7292 ATTN: INTAKE. IF YOU ARE UNABLE TO FAX, PLEASE CONTACT THE NUMBER ABOVE FOR ADDITIONAL SUPPORT.

To complete the referral, click SEND. Once your referral has been submitted, an intake worker will be in contact.