• TVCC Referral Form

    TVCC Referral Form
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  • Referrer Information

  • Child/Youth Information

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    • Services Needed: 
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  • Preschool Speech and Language Questionnaire

    tykeTALK AND Grey Bruce Preschool Speech and Language
    Preschool Speech and Language Questionnaire

  • Preschool Speech and Language Services are managed at TVCC. 

    Grey Bruce (GB) Preschool Speech and Language services are provided in Grey and Bruce counties by TVCC.


    tykeTALK Preschool Speech and Language services are provided in Middlesex, Oxford, and Elgin counties by TVCC, Western University and Woodstock Hospital. 

  • Please answer these important questions about your child. You will be able to talk about your answers with your Speech-Language Pathologist (SLP) during your appointment.

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  • School Referral Information

    School Referral Information
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  • School Therapy Services - SLP

    School Therapy Services - SLP
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  • School Therapy Services - OT/PT

    School Therapy Services - OT/PT

  • Augmentative Communication Service Referral Questionnaire

    Augmentative Communication Service Referral Questionnaire

  • ACS provides assessment and consultation services for children and youth up to their 18th birthday, who are unable to communicate effectively using speech or writing.

    Referral Readiness “Who is ready for a referral to ACS?”

    Face-to-Face Communication: Individuals who are non-verbal or not understood and are purposefully using 20+ symbols* for their every-day communication needs. A child’s use of symbols indicates a willingness and understanding of the need to supplement their current communication and is a predictor of successful use of technology.

    Face-to-Face Communication – Access: Individuals who are non-verbal or not understood and have difficulty physically reaching or pointing to symbols which impacts the number of symbols they use to communicate. Individuals must have known preferences and be using symbols to intentionally communicate.

    Writing: Individuals who have a physical disability which affects their ability to write and/or type. Individuals have the literacy skills to write and have home writing needs but are not able to use paper and pencil and are not able to use a standard keyboard or mouse.

    Consultation Session:  A consultation session is an opportunity for you and other team members (e.g. SLP, OT, Educator) to discuss your child’s communication skills and possible next steps to further develop their use of symbols or communication skills.

    *Why is using 20 symbols important?

    • It indicates the client is aware their speech is not well understood and they are willing to use another method to clarify communication breakdowns
    • The client gains experience using symbols
    • The client gains an understanding of symbols and that they can be used to            communicate 
    • It helps with initial vocabulary selection 
    • It indicates a gap between what the client understands and what they can express
    • It clarifies a client’s desire to communicate

    For more information about Augmentative Communication Services:  https://www.tvcc.on.ca/service/augmentative-communication

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  • Face-to-Face Communication

  • Use of Symbols

  • Verbal Communication

  • Non-Verbal Communication

  • Sign Language

  • Technology Experience

  • Written Communication

  • If possible, please provide current handwriting speed in characters per minute:

    Per minute:

  • If possible, please provide current typing speed in characters per minute:

    Per minute:

  • PABICOP Supplementary Form

    PABICOP Supplementary Form

  • Diagnosis

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  • School

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  • Risk Factors

  • Additional Information:

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  • *Note:

    New or actionable incidental findings should be referred to Neurology/Neurosurgery as indicated, as we do not have those services within our program

  • Autism & Behavioural Services

    Autism & Behavioural Services

  • Autism & Behavioural services are available to clients and families who are registered with the Ontario Autism Program (OAP) and have been given an OAP Client Reference Number. 

  •  If you are looking for information on how to get a diagnostic assessment, please click here: https://www.tvcc.on.ca/resource/accessing-autism-behavioural-services

  •  Services Available, at no cost

    Foundational Family Services consist of a broad range of information, education and consultative services to help families support their child's ongoing learning and development.  To sign up for upcoming events please click here:  https://www.tvcc.on.ca/program/foundational-family-services

     

  •  Services Available, at no cost

    Foundational Family Services consist of a broad range of information, education and consultative services to help families support their child's ongoing learning and development.  To sign up for upcoming events please click here:  https://www.tvcc.on.ca/program/foundational-family-services

    Caregiver - Mediated Early Years (C-MEY) programs support families with young children ages 12 months to 48 months (4years). This 3-6 month program uses a play-based, "caregiver-mediated" approach so that young children can learn new skills and meet individual goals. Programs are free of charge and available for up to six months per child.  Eligible children will receive a letter from the Ministry inviting them to this program. For more information click here: https://www.tvcc.on.ca/caregiver-mediated-early-years

    Entry to School is a six-month group-based program for young children, aged 3-6 years old (as of December 31 in the year that they are starting school) who are entering school for the first time (either kindergarten or grade one). The program  focuses on preparing them to enter school. Following the group-based program, children receive transition supports as they enter school and families and educators can access consultation services during the child's first six months in school. Children will receive a letter from the Ministry inviting them to this program and eligibility will then be determined. For more information click here: https://www.tvcc.on.ca/program/entry-school

     

     

    Services Available for Purchase

    Core Clinical Services (CCS) at TVCC offers Classroom-based, Individual, and Group treatment options for children and youth with autism. 

    CCS may be purchased using OAP funding, other MCCSS sources, or Jordan's Principle funds.

    For more information click here: https://www.tvcc.on.ca/program/core-clinical-services

     

  • Include CCS if you wish to be added to the waitlist while waiting for CCS funding.

  • Paediatric Assessment Clinic Supplementary Form

    Paediatric Assessment Clinic Supplementary Form
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  • Developmental Resources for Infants Consent

    Developmental Resources for Infants is a combination of resources that supports your child's growth and development. Resources are provided from four different community organizations that work together to provide easy-to-access, family-centered services for children 2 years or younger.

  • I agree with the referral to Developmental Resources for Infants. I understand that information about my child and family will be shared with partner agencies: Child and Parent Resource Institute Home Visitng Program for Infants, Children's Hospital, LHSC Development Follow-up Clinic and/or TVCC. This consent is valid for the length of time that my child is receiving services and I understand that I may revoke this consent at any time by contacting intake@tvcc.on.ca or calling 519.685.8716

  • Blind-Low Vision Early Intervention Program Intake Questionnaire

    Blind-Low Vision Services are provided in Middlesex, Lambton, Elgin, Oxford, Huron, Perth, Grey and Bruce counties by TVCC Blind-Low Vision Early Childhood Vision Consultants (ECVCs).
    Blind-Low Vision Early Intervention Program Intake Questionnaire

  • Before you submit your referral.

    If you want to save a copy, click on 'Print Copy' before you submit the referral. Please review your referral before submitting, as forms may only be submitted one time. If you would like to make a correction to your submission, please contact intake@tvcc.on.ca.
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