John McGivney Children's Centre - Online Referral Form

If you’re concerned about a child/youth’s development, we’re here to ensure you get the help you need!

We serve children and youth across Windsor/Essex up to 19 years old, and to 21 if they are in high school. No diagnosis, or physician referral is needed. Anyone can make a referral, including individuals, parents or legal guardians, physicians, and community agencies.

This form can be used for either John McGivney Children’s Centre Services, or for SmartStart Hub Services.

Child/Youth Referral

By clicking on YES, you are stating that consent has been obtained from the Parent/Guardian/Client and we can proceed with submitting the application. Thank you.

YES, Parent/Guardian/Client has agreed to this referral.*

Reason for the Referral

There are concerns about the child/youth's ability to:

Move around

Perform daily activities such as feeding/eating

Understand other people, or tell people what they want

Get along with others, or the way their development impacts their ability to participate in activities

Other

Child/Youth Information

Child/Youth Name

First Name*

Middle Name

Last Name*

Date of Birth*

Age

Gender*

Female

Male

Other/Unknown

How does the Child Identify?

She/Her

He/Him

They/Them

Other

Prefer not to answer

Address

Street Address*

City*

Province

Postal Code

Parent/Guardian 1*

First Name*

Last Name*

Phone*

Is the address the same as the child's?*

Yes No

Street Address*

City*

Province

Postal Code

Is there a Second Parent/Guardian?

Parent/Guardian 2*

First Name*

Last Name*

Phone*

Name of person referring

Your relationship to child/youth:*

Self

Parent/Guardian

Healthcare Practitioner

Community Professional

Other

Please tell us who you are and how we can reach you

First Name*

Last Name*

Phone (main)*

Additional Information

Is an interpreter needed?

Yes No

Does the child/youth attend school or daycare?

School

Daycare

None

School Information

School Name

Daycare Information

Daycare Name

City or Town of the Daycare

Other Agencies involved with the child/youth?*

None

Children's Aid Society

Children First

Connections Early Years Family Centre/Talk 2 Me

NICU (Neonatal Intensive Care Unit)

Regional Children's Centre, Hotel Dieu Grace Healthcare

Private Provider

Unknown

Other

Services Requested

I am looking for services related to:

Augmentative Communication+

Assisting children and youth with severe speech or language problems and/or difficulty holding a pen or pencil and helping them find alternative ways to communicate. Please also fill out this form to tell us more.

Cleft Lip Palate/Craniofacial Dental Program+

A program funded by the Ontario Ministry of Health helping children and youth who were born with facial differences or are diagnosed as having missing or serious conditions affecting their teeth or jaws.

Occupational Therapy+

Assessing, treating and consultation for children and youth to improve or maintain their ability to function and participate in everyday activities.These may include play and school work (productivity), eating, dressing, bathing, hygiene (self-care), or participating in activities with friends in their community (leisure).

Physiotherapy+

Helping children who have difficulties with movement, orthopaedic issues (bone, muscle, joint) and or infants who may be at risk - for example children born prematurely or had difficulties or had difficulties at birth, of meeting their developmental milestones.

Seating & Mobility+

Assessing, consulting and designing supports for children and youth who have difficulties with movement and require equipment (strollers, wheelchairs, etc.) to help improve comfort, posture and their ability to perform daily activities.

Speech & Language+

Preventing, identifying, assessing, treating and rehabilitating speech, language and swallowing/feeding disorders.

Velopharyngeal-Inadequacy (VPI) Clinic+

Assessment and treatment for individuals with resonance disorders - hypernasality, hyponasality, and mixed nasality.

Other

I don't know - I need SmartStart Hub Services to help me get connected to the help I need

Reports

Please upload any reports you wish to share with us. Max 2MB file, pdf, jpeg, png or zip files only please. If you wish to include any additional reports to support this referral, please fax them to 519-252-5873 to the attention of Online Referral Services.

Insert File

Click to select file

Collection and Sharing Consent

Client/Family agree with the collection and sharing of information for the purposes of processing this referral.

Please respond:*

Yes No

If yes, name the person providing consent:

If you have any questions or need assistance completing this referral, please call us at 519-252-7281 or 1-800-976-5622. We can be reached Monday - Friday, 8am-5pm.

To complete the referral, please click SUBMIT, Then, one of our friendly staff will be in contact to follow up.

Thank you for your referral. We've been dedicated to helping children and youth across Windsor-Essex reach their full potential for over 40 years.

Online Referral Form

Child/Youth Referral

Child/Youth Information

Name of person referring

Additional Information

Services Requested

Reports

Collection and Sharing Consent

Questions?