Preschool Speech and Language Referral Form

Getting Started

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This form is used to make a referral for a child for the Preschool Speech and Language Program. To receive preschool speech and language services from Surrey Place and its partners, the child must:

Live in Toronto (M postal code)
Be preschool-aged (from birth until May 31 of the year they start full-day kindergarten)
Have speech and language difficulties.

If the child lives outside of Toronto, find a Preschool Speech and Language program near you through Preschool Speech and Language Program | ontario.ca.

^*Who is filling out this form?

Parent/legal guardian

Healthcare provider supporting a family

Other

Eligibility

^*Has this child previously registered for or received preschool speech and language services provided by Surrey Place or their partners?

Yes

Unsure

^*Child's date of birth

^*Has the child been diagnosed with a permanent hearing loss?

YesNo

calculations

Age bracket items based on birth date.

[age-years]

[age-months]

[age-months-this-year]

to display age in 'x' years & 'y' months, this is calculating 'y'

Age eligibility items. Based on the birth date, current date, and eligibility cutoff date.

[current-year]

[birth-year]

[current-year-minus-4-years]

[todays-date]

[psl-eligibility-cutoff-date] current year May 31st

this date is ok, AFTER this date is not allowed

Adjust this date in Live to match Surrey's requirements. In dev, stage, sandbox feel free to modify this for testing purposes.

[stuttering-cutoff-date] current year, July 31st

this date is ok, AFTER this date is not allowed

Up until this date, children who answer Yes to the stuttering question, born in current year - 4 years, can still submit a referral.

[display-age-confirmation-box]

[skip-to-basic-contact-questions]