Niagara Children's Centre Physicians/Primary Care/Healthcare Partners

Request Form

Child's Demographic Information

Child must reside in Niagara

Healthcare Provider Information

Parent with Custody/Legal Guardian Information

Or the person who should be contacted for intake
Parent, legal guardian, FACS professional

Services Requested

The decision for the specific services offered to the child/family will be decided by the Intake Coordinators based on the Centre's eligibility criteria and service delivery models.
SmartStart Hub Services are available to any family who resides in Niagara with a concern about their child’s development. Niagara Children’s Centre Services are provided for children with diagnosed or suspected Physical, Developmental, or Communication delays and disabilities.

For detailed eligibility requirements by program, please visit our website at and/or see our Birth-School Start OT/PT/SLP Referral Checklists.

Areas of Concern

MANDATORY FOR ALL REFERRALS unless notes/reports are uploaded

Additional Information

If PSL-IHP-BLV or CTC transfer, reports must be uploaded (if PSL-IHP-BLV, must include Transfer Form and ISCIS report)


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