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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.

* Indicates mandatory fields.

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

Child/Youth Information

Child/Youth Name
Parent/Guardian 1*
Is the address the same as the child's?*
Parent/Guardian 2*

Name of person referring

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

Additional Information

School Information
Daycare Information

Services Requested

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.
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.
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).
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.
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.
Preventing, identifying, assessing, treating and rehabilitating speech, language and swallowing/feeding disorders.
Assessment and treatment for individuals with resonance disorders - hypernasality, hyponasality, and mixed nasality.


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.

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.


Contact us at
Email: or
519-252-7281 / 1-800-976-JMCC (5622)