KidsAbility Online Referral Form

Date:

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

Reason:

Name of Person Completing the Form:

Relationship to Client:

Agency (if applicable):

Contact Number:

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

Last Name:

First Name:

Date of Birth (mm/dd/yy):

Gender:

Address:

City:

Postal Code:

County:

Child Care or School Information

School/Daycare:

City:

Parent or Caregiver Information

Parent/Caregiver #1 Last Name:

First Name:

Relationship:

Legal Guardian:

Yes No

Address Same as Client:

Yes No

If no, please specify Home Address:

City:

Postal Code:

Preference for Contact:

Home Cell Work E-mail

Home Phone Number:

Cell Phone Number:

Work Phone Number:

Email Address:

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

Comments:

Parent or Caregiver Information

Parent/Caregiver #2 Last Name:

First Name:

Relationship:

Legal Guardian:

Yes No

Address Same as Client:

Yes No

If no, please specify Home Address:

City:

Postal Code:

Home Phone Number:

Cell Phone Number:

Work Phone Number:

Email Address:

Additional Information

Language Spoken at home:

Other Languages (if applicable):

Interpreter Required:

Yes No

Diagnosis (if any):

Allergies:

Medications:

Physician #1 Name:

City:

Physician #2 Name:

City:

Other Contact:

City:

Agency/Specialty:

Collection and Sharing Consent

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

Please respond:

Yes No

If yes, name the person providing consent:

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.

Additional Documentation has/will be faxed:

Yes No