Niagara Children's Centre Physicians/Primary Care/Healthcare Partners
Request Form
Child's Demographic Information
*
First Name
*
Last Name
*
Date of Birth
Child must reside in Niagara
*
Street Address
Unit
*
City/Town
*
Postal Code
Healthcare Provider Information
*
First and last name
*
Phone
Extension
*
Fax
Healthcare Provider Organization (if applicable)
Parent with Custody/Legal Guardian Information
Or the person who should be contacted for intake
*
First Name
*
Last Name
*
Relationship to child
Parent, legal guardian, FACS professional
*
Primary Phone
Mobile phone is the same as primary phone
Mobile Phone
Email
*
Service is available in English and French. Will the contact identified above need an interpreter for another language on the intake call?
Yes
No
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
www.niagarachildrenscentre.com/referrals
and/or see our
Birth-School Start OT/PT/SLP Referral Checklists
.
I am making a referral for the following service(s)
SmartStart Hub at Niagara Children's Centre
Birth to School Start Occupational Therapy
Birth to School Start Physiotherapy
Birth to School Start Speech-Language Pathology
Age 0-18 Gait Clinic: initial referral must come from physician specializing in physical, orthopedic, neurological or neuromuscular medicine only
0-18 Seating and Mobility Clinic
0-18 Casting and Splinting Clinic: initial referral must come from physician specializing in physical, orthopedic, neurological or neuromuscular medicine only
0-18 Home and Vehicle Modification Clinic
0-18 Augmentative and Alternative Communication
0-18 School-Aged Active Rehabilitation
School Start-18: School-Age Equipment Needs
Medical Clinics (Physician referral only): ASD Assessment/Pediatric Neurology Clinic /Neurodevelopmental Clinic/Physical Medicine and Rehabilitation
Areas of Concern
MANDATORY FOR ALL REFERRALS
unless notes/reports are uploaded
Select all areas of concern that apply
Feeding
Communication
Motor/Mobility
Self-Care/Self-Help
Sensory processing
Behaviour or Emotional/Mental Health
Comments
Additional Information
If PSL-IHP-BLV or CTC transfer, reports must be uploaded (if PSL-IHP-BLV, must include Transfer Form and ISCIS report)
Attach any pertinent documentation here such as:
Birth-School Start OT/PT/SLP Referral Checklists
Other reports/notes
Additional Comments
Consent
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