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

*Do you consent to a virtual appointment? YesNo If your child is eligible for services, the SLP will provide more details regarding the virtual appointment.

*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, Lansdowne 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 MarriedCommon-LawNever Married or Never Common-LawSeparatedDivorcedWidowed

Is there a legal custody arrangement?

If yes, please describe the arrangement. JointSole MotherSole Father

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

Children's Aid SocietyCatholic Children's Aid Society

Worker Name

Phone ext.

__________________________________________________________________

Who else lives in the home?

In relation to the child

Name Age

BrotherSisterGrandparentAuntUncleFriendBorderOther

if other, please describe

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In relation to the child

Name Age

BrotherSisterGrandparentAuntUncleFriendBorderOther

if other, please describe

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In relation to the child

Name Age

BrotherSisterGrandparentAuntUncleFriendBorderOther

if Other, please describe

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In relation to the child

Name Age

BrotherSisterGrandparentAuntUncleFriendBorderOther

if Other, please describe

__________________________________________________________________

School and Child Care Experiences

*Does your child attend Childcare or Preschool Yes, please fill in belowNo

Name of Child Care Days Attending

Centre-based care? YesNo, please describe the type of care

Resource Teacher Involved? YesNo

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? YesNo

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? YesNo

Are there any other professionals involved with your child? YesNo

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? NoYes, please describe

Funded by the Government of Ontario.