KidsInclusive - Complex Special Needs (CSN)

🇨🇦English

🇨🇦En

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?

YesNo

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?

Select one

^*Date of birth

^*Address

Apartment/suite, P.O Box, etc.

^*City

Province

Postal code

Custody Status

^*What is 's custody status?

Select one

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?

YesNo

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 Centre for Child & Youth Development, 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.