KidsInclusive - Complex Special Needs (CSN)

Complex Special Needs

by KidsInclusive Centre for Child & Youth Development

What to Expect:

Complete this service request in just a few moments.

Once completed, the parent/guardian will receive a call to gather consent to send the CSN Referral Screener and its embedded documents to the Child Parent Resource Institute for review.

You can download a copy of this for your records at the end of this process.

Has a parent or legal guardian with custody consented to this service request? *

Yes

Referral Source Information

Your first name *

Your last name *

Agency *

Phone *

Extension

Email *

Child/Youth's Information

Child/youth's first name *

Child/youth's last name *

Which region best describes where lives? *

Date of birth *

Address *

Apartment/suite, P.O Box, etc.

City *

Province

Postal code

Custody Status

What is 's custody status? *

Legal Guardian Contact Information

First name *

Last name *

Relationship to *

Mother

Father

Kinship

Family & Childrens Services Agency

Other

Primary phone *

Extension

Secondary phone

Extension

This contact has the same address as ? *

Yes

Is there a secondary contact?

Yes

Language

What is 's first spoken language? (If does not speak yet, which language is used most at home?) *

Select "other" if speaks more than one language.

English

French

Other

What is the preferred service language? *

English

French

Other

Additional Information

Please attach the CSN Referral Screener with its embedded contents including Coordinated Service Plan and all additional documents

By submitting this form, I agree to send this personal information to KidsInclusive, for the purpose of requesting Complex Special Needs. I have the consent/authorization to send the information about any other people that may be included on this form (e.g., a client, parent, child).

I agree to these Terms and Conditions and Privacy Policy, which outline how this personal information is kept safe.