Child Development Referral Form

Child Development Referral Form

The cutoff date for referral for therapy services is January 30th of the child's pre-kindergarten year

Child's Name(Required)

First Last

Child's Birth Date(Required)

MM slash DD slash YYYY

Does the child have a diagnosis and/or are you wondering about Autism, ADHD, Developmental delays?

Yes

No

Please Specify:

The child lives with:

Both parents

One parent only

Foster family

Other:

The Legal Guardian for this child is:

Both parents

One parent only

Gov't Guardian

Other

Parent, Legal Guardian, Foster Family Name:(Required)

First Last

Address

Street Address City Postal Code

Phone (Home):

Work

Cell

Preferred Email(s):

Parent, Legal Guardian, Foster Family Name:

First Last

Address

Street Address City Postal Code

Phone (Home):

Work

Cell

Preferred Email(s):

Is the child Indigenous (that is, First Nations, Métis, or Inuk?)

Yes

No

Language(s) spoken at home:

Would an interpreter be helpful?

Yes

No

Is the child attending daycare?

Yes

No

Daycare name:

Days and hours of attendance:

Services or Consultations Requested:

Please provide specific reasons why you are requesting services or consultations at the Sundrops Centre for Child Development.

Infant Development

The Infant Development Program provides a program to families with children birth to three who have a developmental delay or are identified at risk for delay. In specific instances, service may be extended up to school entry. Goal oriented supports are provided in the family's home or community.

Feeding Services

Sundrops feeding services are not an urgent care service. Families with urgent feeding needs are directed to begin receiving services with the appropriate service provider. Sundrops provides feeding assessment and consultation services for children between 0-5 years of age and typically consists of an SLP and OT team. The team aims to work collaboratively with other service providers involved such as the family doctor, pediatrician, dietitian, public health nurse, and lactation consultant.

Occupational Therapy

Occupational Therapist’s look at functional areas of children’s development that they need additional support in. These areas include self-care (ie. bathing, dressing, feeding, toileting, sleep), productivity (ie. participating in group settings, sensory processing challenges, fine and visual motor skills, attention to tasks) and leisure (ie. play, social interactions).”

Physical Therapy

A physiotherapist provides treatment, assessment, recommendations and training in age appropriate activities to support children with gross motor skills. Physiotherapy can help to correct and prevent disabilities associated with disease, injury, congenital deformity or developmental delay.

Speech Language Therapy

Speech language pathology supports the development of skills related to speaking, communicating and swallowing. This includes areas such as developing speech sounds and speech clarity, language understanding and expression, social communication, imaginative play skills, literacy, appropriate use of voice, smooth stutter-free speech, and feeding/swallowing.

Supported Child Development

Supported Child Development (SCD) is a community based program that assists families of children with extra support needs to access inclusive child care that meets family needs.

Professional Contact Information

Family Doctor

Family Doctor Phone:

Pediatrician

Pediatrician Phone:

Other

Other Phone:

Referral Source who assisted to make the referral

Name

First & Last

Date

MM slash DD slash YYYY

Family is aware of referral

Yes

No

Email Communication

Yes

No

I consent to receive communications from Clements Centre for Families by email

The private and personal information collected on this form is used to determine eligibility and appropriateness of services to be provided. Non-identifying statistical information may be collected, collated and distributed to support requests for funding, advocacy, resource allocation and measuring outcomes. Please refer to the Personal Information Protection Act