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Preschool Speech and Language Program Referral Form

Affiliated Services for Children and Youth Inc. (Early Words) operates under an implied consent model. Please read our Privacy Policy available at the bottom of the website.

    *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. Click Here

    *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  

    Does your child respond when you call his/her name? (i.e. by turning to look at you, or stopping what they are doing) YesNo

    Does your child take your hand and pull you to something he/she wants? (i.e. to the fridge to get a drink) YesNo

    Does your child have any characteristics or play behaviours that are unique or that you are concerned about? (i.e. Lines up toys, no eye contact, spins wheels rather than driving the car) YesNo

    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

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    In relation to the child

    Name  Age

    if other, please describe

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    In relation to the child

    Name  Age

    if Other, please describe

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    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?

    Funded by the Government of Ontario.