Client Services Intake Centre 2695 North Sheridan Way, Suite #120, Mississauga, ON L5K 2N6 Tel: 905-855-3557/Toll Free: 1-877-ERINOAK (1-877-374-6625) /Fax: 905-855-9451
Website: www.erinoakkids.ca
Referral Date:
Referral Form
(Please Print) Please complete ALL SECTIONS of this form. INCOMPLETE FORMS WILL BE RETURNED. Please check program requested: Central West Infant Hearing Program Central West Blind Low Vision Program (ophthalmologic referral required) Child and Youth Rehabilitation Program (referral required) Autism Intervention Services (confirmed diagnosis required) Halton Peel Preschool Speech and Language Program ADRS Only - Medical Referral Required
CLIENT INFORMATION: NAME: Surname DATE OF BIRTH: Day ADDRESS: / / Month Year First name Male Female Middle Initial
POSTAL CODE: HEALTH CARD NUMBER:
TELEPHONE: (
)
VERSION CODE:
If no OHIP, please list other insurance information:
Client lives with:
Both parents
Father Yes
Mother
CAS
Foster
Group Home
Other
Interpreter Services Required?
No If Yes, please specify language: Yes No Yes No
Does this client have a sibling who is also a client of ErinoakKids?
Allergies:
Epipen Required?
PARENT INFORMATION (complete only if different from client): MOTHER: ADDRESS: FATHER:
POSTAL CODE: DAD’S WORK: ( MOM’S WORK: ( Rev. May 2009
) )
TELEPHONE: ( DAD’S CELL: ( MOM’S CELL: (
)
)
)
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MEDICAL INFORMATION (to be completed by physician only): Client’s diagnosis, if known: Diagnosis you are querying: Reason for referral. Please provide a brief history, copies of relevant investigations, positive findings and current medication information.
REFERRING M.D. (required for Rehabilitation Program):
Name: Address: Telephone: Signature: ( ) Fax: ( ) Billing Number: ________________________
PRIMARY CARE PHYSICIAN (complete only if different from referring physician):
Name: Address: Telephone: ( ) Fax: ( )
OTHER COMMUNITY AGENCIES AND/OR PROFESSIONALS INVOLVED:
Name: Name: Name: Telephone: Telephone: Telephone:
(For Internal Use Only)
Date of phone contact: Date and Time of Appointment: Physician’s Name: Form Completed by:
Rev. May 2009
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