Early Words Preschool Speech and Language Program Referral Form

This online referral form:

  • is for families who want to access Early Words preschool speech and language services
  • can be completed for children from 6 months of age up to a child’s entry into his/her junior kindergarten year (August 31st cut off for eligibility)
  • is offered as an alternative option to you making a phone referral by calling our referral number 905-381-2828 ext. 224
  • needs to be completed in one sitting, it cannot be saved
  • is for families who live in the City of Hamilton
  • will take 10 – 15 minutes to complete

Please note:

  • If you are concerned that your child has other developmental challenges in addition to speech and language needs, please contact:

    Developmental Pediatrics and Rehabilitation – Intake Department
    905 -521-2100 ext. 77950
    Located at the Ron Joyce Children’s Health Centre, McMaster Children’s Hospital

    Additional information on services and a copy of the referral form can be found on their website.

    www.mcmasterchildrenshospital.ca/dprreferral

  • A separate referral will need to be made for each additional child that you would like to refer.
    If you have any questions or need help, call 905-381-2828 ext. 224 Monday to Friday from 8:00 am – 4:00 pm.

Early Words speech and language assessment appointments take approximately one hour.

For more information on how to prepare for an appointment with a Speech-Language Pathologist click here

The Early Words online referral process has two parts:

  1. Fill-out the following online referral form
  2. Confirm your referral and complete the process with the Early Words Referral Office.  You will be  contacted by phone within 3 business days of your online request

PLEASE NOTE:
Your child will need a valid Health Card to receive Early Words Services.  You can get or renew a Health Card at any Service Ontario location.  Click here for more information

Don’t forget to press “SEND THE MESSAGE” when you are finished the online form.

You will receive an email to confirm that your referral has been received by the Early Words Intake Office.


Privacy Statement

Privacy of personal information is important to the programs and services of Affiliated Services for Children and Youth (ASCY). Our agency is committed to collecting, using and disclosing personal information in a responsible manner and only to the extent necessary for the services we provide. We try to be open and transparent about how we handle personal information.

The information collected will be used to process your referral to Early Words, the Hamilton Preschool Speech and Language Program. Early Words/1st mots is a Ministry of Children & Youth Services Program and is a program of Affiliated Services for Children and Youth (ASCY). Participating Early Words agencies are Affiliated Services for Children and Youth, Hamilton Health Sciences - McMaster Children’s Hospital - Ron Joyce Children's Health Centre and St. Joseph’s Healthcare Hamilton. Together, these agencies form a regional service for preschoolers with speech, language and communication difficulties living in Hamilton. Each partner agency has their own Privacy Statement and Privacy Officer.

The Personal Health Information Protection Act (PHIPA), 2004 is in place to ensure the protection and privacy of your personal information. Your information will only be used for the purposes of ASCY’s Early Words Preschool Speech and Language Program in the manner described below.

Early Words Preschool Speech & Language Program

Since the program began in 1998, the provincial government has required the collection of data of children and families receiving services. The data is stored at the Ministry in the Healthy Child Development Integrated Services for Children Information System (HCD-ISCIS) and is available only in anonymized form (i.e., contains no identifying information) to Ministry of Children & Youth Services staff. The type of data stored can include output data (e.g.: wait time to assessment, type of intervention received), outcome data (e.g.: change in skills over time) and demographic information (e.g.: child’s age, home language used, severity of delay). As an agency working with personal health records, ASCY’s Early Words Preschool Speech and Language Program is accountable to comply with all relevant legislation including the Personal Health Information Protection Act (PHIPA), 2004.

What is Personal Health Information?

Personal health information is information about an identifiable individual. Personal health information includes information that relates to:

  • the physical or mental health of an individual including family history
  • the provision of a service or health care to an individual including identifying the individual’s health care provider (i.e.: family physician, social worker, etc.)
  • a plan of service of treatment
  • non-health information (i.e: home contact information, etc.)
  • substituted decision-maker, when relevant

Why We Collect Personal Health Information

We collect, use and disclose personal health information when providing service to your child. The primary purpose for collecting personal health information is to provide speech and language therapy and interventions including parent education. To best serve your child and family, we collect information about your child and family’s health history, gather information to assess your child’s need for speech and language interventions and to determine which options may be best suited to your child and family. We limit the collection of information to what is required to provide service to your child and family.

The types of information we collect may include:

  • Child’s name
  • Child’s date of birth
  • Age
  • Gender
  • Names of parents/legal guardians
  • Home address
  • Contact information/phone numbers
  • Marital Status
  • Custody arrangement
  • Other family members living in the home
  • Languages spoken in the home
  • School and child care experiences
  • Name of family physician
  • Health history
  • OHIP #
  • Records of when the child was seen by Early Words clinicians

There are times when we may gather personal health information about your child from other places, if the parents/guardians have given us consent or if the law permits.

Parents and legal guardians may withhold or withdraw their consent for some of the uses outlined below. There may be legal exceptions that apply. If the personal health information is withdrawn by the parents/legal guardians, the consent is withdrawn as of the date the request is made and is not retroactive. Withdrawing consent or not giving permission to share information with, within and outside Early Words may limit a child’s access to services from Early Words agencies or from specialized health services. The Early Words Speech-Language Pathologist will explain the effects of such decisions.

Use of Personal Information

Personal information shared is used to:

  • Assess the best course of treatment option for your child based on his/her strengths
  • Communicate with other providers involved with your child
  • Plan, administer and manage our internal operations such as booking appointments, completing required statistics (anonymized), teaching authorized staff for data inputting purposes, etc.
  • Monitoring our systems by conducting periodic risk audits
  • Obtaining your feedback through quality improvement activities such as the completion of satisfaction surveys
  • Teach students and provide continuing education to our staff
  • Meet our obligations with the Ministry of Children and Youth Services (MCYS)
  • Comply with legal and regulatory requirements
  • Handling of Personal Information

    We realize the information being shared requires utmost privacy and protection. The HCD-ISCIS is an electronic system which is password protected and only accessible to authorized staff of ASCY’s Early Words Program. In addition, the following practices are adhered to:

    • Paper information is either under supervision by authorized staff or secured in a locked or restricted area
    • Electronic hardware is either under supervision by authorized staff or secured in a locked or restricted area. Strong passwords are used on all computers containing personal information
    • Personal health information is only stored on mobile devices if necessary. Strong encryption is used to protect mobile devices and they are kept in a locked area or under the direct supervision of authorized staff
    • Electronic information is encrypted using a strong password before being transmitted
    • Our staff members are trained to collect, use and disclose personal information only as necessary to fulfill their duties and in accordance with our agency’s privacy policy
    • Personal information would never be posted on social media sites and our staff are trained on the appropriate use of social media sites
    • Paper information is transferred through sealed, addressed locked containers or couriered by reputable companies with strong privacy policies
    • We take all reasonable steps possible to make sure the personal health information shared is protected against loss, theft, unauthorized use or disclosure. We also ensure the records containing personal information are protected against unauthorized copying, modification or disposal. In the event of a breach of confidential personal information, we will notify the parents/legal guardians at the first reasonable opportunity that the information was stolen, lost or accessed by unauthorized persons.

      Retention and Disposal of Personal Information

      We need to retain personal information for a period of time to ensure that we can answer any questions you may have about the services provided and for our own accountability to external regulatory bodies. Therefore, records are kept for ten years following the child’s 18th birthday, unless exceptional circumstances warrant the retention for a longer time period.

      Records will be disposed of in a secure manner and in such a way that the records cannot be reconstructed (i.e.: paper records are cross-cut shredded, electronic files/hardware will be deleted or destroyed so records cannot be recovered).

      Access to Personal Health Information

      With only a few exceptions as per the legislative requirements of PHIPA, you have the right to see what personal information we have on file by contacting our Privacy Officer. We can help you identify what records we might have about you. We will also try to help you understand any information you have questions about (e.g.: short forms, technical language, etc.) In order to release personal health information, we will need to confirm your identity, if we do not know you, before we provide access to any information. We reserve the right to charge $30.00 for the first twenty pages of records and 25 cents for each additional page.

      We will respond to a request for access to information as soon as possible and no later than 30 days after receiving the request, however, we may extend the time for a response by another 30 days if necessary. If the request for access to information is refused, we will provide the reason for the refusal. It is within your right to make a complaint to the Information and Privacy Commissioner of Ontario.

      Release of Information

      If we receive a special request for release of personal health information that is beyond your initial consent, then we will get in touch with you to outline the reason and obtain your permission.

      Correction to Personal Health Information

      We will consider any requests to correct personal health information within the legislative requirements of PHIPA. If you believe there is a mistake in the information we have about you on file, you have the right to ask for it to be corrected. This applies to factual information and not to any professional opinions or observations made in good faith. We may ask you to provide documentation that our files are wrong. Where we agree that we made a mistake, we will make the correction. At your request and if it is reasonably possible, we will notify anyone to whom we sent this information however, we can deny the request if it does not reasonably have an effect on the ongoing provision of health care. If we do not agree that we made a mistake, we will still agree to include a brief statement from you on the point in question in our file. It is also within your right to make a complaint to the Information and Privacy Commissioner of Ontario.

      Privacy Committee

      The Privacy Committee consists of the Privacy Officer, Early Words Co-ordinator and Executive Director of ASCY and is responsible for overseeing all aspects of privacy practices at ASCY’s Early Words Preschool Speech and Language Program. This Committee will meet on an ad-hoc basis with regional system partners Hamilton Health Sciences - McMaster Children’s Centre and St. Joseph’s Healthcare Hamilton to collaborate on privacy practices and policies for the system.

      While we take precautions to avoid any breach to your privacy, if there is a loss, theft or unauthorized access of your personal health information we will notify you. Upon learning of a possible or confirmed breach, we will do our best to contain the breach to the best of our ability by doing any or all of the following depending upon the circumstances:

      • Retrieve hard copies of personal health information that has been disclosed and ensure no copies have been made
      • Take steps to prevent unauthorized access to electronic information such as change passwords, temporarily shut-down the system, restrict access, etc.
      • We will provide our contact information and the Commissioner’s contact information to the affected individuals should they have further questions
      • We will investigate and remediate the problem by determining what steps should be taken to prevent future breaches (e.g.: taking additional safeguards, changes to policies and practices, providing additional staff training, etc.)
      • We are required to report any breaches to the Ontario Ministry of Children and Youth Services and depending upon the circumstances, we may also notify and work with the Privacy Commissioner of Ontario. If we believe that the breach was a result of professional misconduct, incompetence or incapacity, we will report the breach to the relevant regulatory College.

        Contact Information

        The Privacy Officer at ASCY shall ensure that employees and other agents of the Early Words Regional System are appropriately informed of their duties under the PHIPA. If you have any questions or for more information about our privacy protection practices, please contact us:

        Joyce Minten
        Director of Organizational Effectiveness
        526 Upper Paradise Road
        Hamilton ON
        905-574-6876 ext. 226
        jminten@ascy.ca (do not send personal information via email)

        If you wish to make a formal complaint about our privacy practices, we ask that you place it in writing to our Privacy Officer. She will acknowledge receipt of your complaint and ensure that it is investigated promptly and that you are provided with a formal decision and reasons in writing.

        You have the right to contact the Information and Privacy Commissioner/Ontario if you think we have violated your rights. The Commissioner can be reached at:

        Information and Privacy Commissioner/ Ontario
2 Bloor Street East, Suite 1400 Toronto ON M4W 1A8
 Telephone (416) 326-3333 or 1-800-387-3333 Fax (416) 325-9195

        Accept Disclaimer
        __________________________________________________________________

        *Required Fields

        *How did you hear about us?

        *Does the child live in the Hamilton Area? YesNo
        The Hamilton Area includes: Ancaster, Binbrook, Carlisle, Carluke, Copetown, Dundas, Elfrida, Flamborough Centre and West, Freelton, Greensville, Hamilton, Hannon, Jerseyville, Lynden, Millgrove, Mount Hope, Mountsberg, Rockton, Sheffield, Stoney Creek, Strabane, Tapleytown, Troy, Waterdown, Westover, Winona, and Woodburn.

        *Is the child on a waitlist or receiving services anywhere else? (e.g. McMaster Children's Hospital, Chedoke Hospital, Contact Hamilton, Ron Joyce Children's Health Centre, Developmental Pediatrics at Chedoke, The Hospital for Sick Children, ErinOak Kids, Landsdowne Children's Centre, etc.)
        YesNo

        If Yes, where    

        And for what services:

        Please note:

        If you are concerned that your child has other developmental challenges in addition to speech and language needs, please contact:

        Developmental Pediatrics and Rehabilitation - Intake Department
        905-521-2100 ext. 77950 (Located at the Ron Joyce Children’s Health Centre, McMaster Children’s Hospital)

        Additional information on services and a copy of the referral form can be found on their website. www.mcmasterchildrenshospital.ca/dprreferral

        *Please describe the reason for your child's referral to Early Words. (e.g., Why are you concerned about your child's speech and/or language development? Who suggested that you contact us and why?)

        *Your First and Last Name    

        *What is your relationship to the child      

        __________________________________________________________________

        *Child's First and Last Name

        *Child's Date of Birth. Please use the format YYYY-MM-DD. For example, the birthday of January 31st, 2012 would be written as 2012-01-31.  

        *Gender MaleFemaleOther

        __________________________________________________________________

        *Your Full MAILING Address. Please be sure to include the street address, the apartment or unit numbers, the city and the postal code.

        *Phone Numbers   ext.
                                    ext.
                                    ext.

        *Your Email  

        __________________________________________________________________

        *Was the child a full term baby? YesNo, please describe 

        Was the child followed by Neo-Natal Clinic at McMaster Children's Hospital (formerly known as the Growth & Development Clinic)?  YesNo

        *What age did the child start walking?

        *Does the child play well with other children? YesNo, please describe 

        *Are there any other Health Concerns about this child? NoYes, please describe  

        Are there any Specialists Involved in the child's care?

        Other than speech and/or language skills, do you have any concerns about how the child is growing or developing? NoIf Yes, please describe 

        *Has anyone mentioned any concerns about the child's growth or development? NoIf Yes, please describe  

        Have any possible diagnoses been suggested? NoYes, please describe  

        __________________________________________________________________

        Family Information

        Language(s) Spoken at Home

        Name of person(s) who have legal decision-making rights for this child:

        *Your Marital Status

        Is there a legal custody arrangement?

        If yes, please describe the arrangement.

        If the custody arrangement is solely with one parent, does the other parent have access? YesNo

        Please describe any other information that you feel Early Words should know about the child's legal custody arrangement.  

        __________________________________________________________________

        Parent/Guardian 1   Relationship to child

        First and Last Name

        Full Mailing Address if different than above

        Please be sure to include street address, apartment or unit numbers, city and postal code

        Phone ext.

        Occupation
        __________________________________________________________________

        Parent/Guardian 2   Relationship to child

        First and Last Name

        Full Mailing Address if different than above

        Please be sure to include street address, apartment or unit numbers, city and postal code

        Phone ext.

        Occupation
        __________________________________________________________________

        Parent/Guardian 3   Relationship to child

        First and Last Name

        Full Mailing Address if different than above

        Please be sure to include street address, apartment or unit numbers, city and postal code

        Phone ext.

        Occupation
        __________________________________________________________________
        Children's Aid Involvement

        Worker Name

        Phone ext.

        __________________________________________________________________

        Who else lives in the home?

        In relation to the child

        Name  Age

        if other, please describe

        ------------------------------------------------------------------

        In relation to the child

        Name  Age

        if other, please describe

        ------------------------------------------------------------------

        In relation to the child

        Name  Age

        if Other, please describe

        ------------------------------------------------------------------

        In relation to the child

        Name  Age

        if Other, please describe

        __________________________________________________________________

        School and Child Care Experiences

        *Does your child attend Childcare or Preschool

        Name of Child Care   Days Attending

        Centre-based care?

        Resource Teacher Involved?

        Name of Resource Teacher
        ___________________________________________________________________

        SCHOOL

        *Please select the Grade your child will be entering in the next calendar September.
        NEXT Grade Level your child will enter the following September

        Name of School   Days Attending

        Resource Teacher Involved?

        Name of Resource Teacher

        ____________________________________________________________________

        Doctor Information

        *Family Doctor's Name City

        *Can we send a letter to your child's family doctor to let them know a referral to Early Words has been made?

        Are there any other professionals involved with your child?

        Would you like them to receive a letter to confirm a referral to Early Words?

        Name   City

        Consent?YesNo

        Name   City

        Consent?YesNo

        ____________________________________________________________________

        HEARING

        *Do you have any concerns about your child's hearing skills?


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