• TVCC Referral Form

    TVCC Referral Form
  • Submission Date
     - -

  • Referrer Information

  • Relationship to the referred?*
  • Format: (000) 000-0000.
  • Please specify role at school:*
  • Are you the Legal Guardian for the Child/Youth being referred?*
  • As a Legal Guardian, do you
  • If Child/Youth is in care of CAS who does the Child/Youth live with?*
  • Is this the family physician?*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Child/Youth Information

  • Date of Birth*
     - -
  • Gender*
  • Pronoun*
  • Does the child/youth have their own cell and/or email
  • Format: (000) 000-0000.
  • HC Expiry Date
     - -
  • Are Interpretation Services Required*
  • Would you like services to be provided in French?
  • Relationship to child/youth:*
  • Primary Guardian Address*
  • Preferred Contact Number*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Is there a Second Parent/Guardian?*
  • Does the Second Parent Guardian:*
  • Relationship to child/youth
  • Same Address as Client*
  • Second Parent/Guardian Preferred Contact Number*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Does the client/youth attend school or daycare?:*
  • I was able to find my child/youth school/daycare?*
    • Services Needed: 
    • I am looking for service(s) related to....
    • Please indicate the agency contracting the services:
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    • Service(s) required:
    • Physician referral required for the services below. May include PT,OT,SLP,SW and RN.
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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. 

  • Consent: Preschool speech and language services are managed at TVCC. Services are provided by TVCC, Western University or Woodstock Hospital depending on where you live. Do you provide TVCC with consent to start a record on your child and share information with the agency providing service when needed?*

  • 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.

  • Has your child been seen by a SLP?*
  • Date of SLP Assessment
     - -
  • Do you have another child who is seeing a Speech-Language Pathologist?*
  • Please indicate if your child: (check all that apply)*
  • Does your child stutter (e.g., repeats words, sounds, or phrases when speaking)?*
  • Was your child's hearing screened through the Infant Hearing Program?
  • Are you concerned about your child's hearing?*
  • Are you concerned about your child's eating?*
  • If "Yes" does your child do any of the following:*
  • Are you concerned about your child's drinking?*
  • If “Yes” does you child do any of the following:
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  • School Referral Information

    School Referral Information
  • Format: (000) 000-0000.
  • Indicate which service(s) you are requesting for your student*
  • I confirm*
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  • School Therapy Services - SLP

    School Therapy Services - SLP
  • Format: (000) 000-0000.
  • Areas of Need*
  • Articulation/Phonology: Level of severity in single words:*
  • Motor Speech Characteristics*
  • Intelligibility rating (to familiar and unfamiliar listeners)*
  • Client has the appropriate receptive and expressive language skills required for successful therapy*
  • Client has the attention, motivation, and ability for successful participation*
  • Client has intent to communicate verbally*
  • Fluency: Level of Severity*
  • Voice Resonance: Did you direct parent to contact their physician for
  • Voice Resonance: Level of Severity of Impact on Daily Communication:*
  • Voice Resonance: Are SLP services required for post surgical needs?*
  • Non Speech/Augmentative Communication (AC)
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  • School Therapy Services - OT/PT

    School Therapy Services - OT/PT
  • Please indicate areas of need for your student (select all that apply)*
  • There is an adult available at the school to collaborate with the STS OT?*

  • 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

  • This referral is:*
  • Date of last ACS Involvement
     - -
  • Does your child/youth currently work with:
  • Is SLP an A.D.P. Individual Authorizer?*
  • Format: (000) 000-0000.
  • Is OT an A.D.P. Individual Authorizer?*
  • Format: (000) 000-0000.
  • Service(s) Requested:*
  • Consultation Session

  • Face-to-Face Communication

  • Face-to-Face Assessment: (PLEASE CONFIRM BY CHECKING ALL) This person is non-verbal or not understood AND:*
  • Face-to-Face with Access Needs Assessment: (PLEASE CONFIRM BY CHECKING ALL) This person is non-verbal or not understood AND*
  • This person communicates with others using:*

  • Use of Symbols

  • Does this person combine symbols?*

  • Verbal Communication

  • Non-Verbal Communication

  • Non-verbal communication includes:*

  • Sign Language

  • Technology Experience

  • Have you tried any technology for communication?*

  • Written Communication

  • Can this person combine letters or symbols to create words or messages?*
  • Can this person use a standard keyboard/mouse to meet their writing needs?*
  • Please list any assistive technology that has been tried:

  • 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

  • Diagnosis:*
  • Date of injury/illness:*
     - -
  • Date of diagnosis of injury, if different from date of injury:
     - -

  • School

  • Is this child/youth currently attending school?*
  • Is there an anticipated return date?
     - -

  • Risk Factors

  • Are there any risk factors that may complicate recovery? (check all that apply)*
  • Prior developmental diagnosis, please specify:*
  • Prior psychiatric diagnosis, please specify:*
  • Substance abuse, please specify:*

  • Additional Information:

  • For children with headaches, is the child using analgesia?*
  • Has a medication holiday been completed??*
  • Have the following been completed?
  • What symptoms are currently impacting the child/youth's function? (check all that apply)*
  • Were any of these symptoms a concern prior to illness/injury?*
  • Has neuroimaging been completed?*
  • CT Date
     - -
  • MRI Date
     - -
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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
  • For children with sleep disruption, indicate what has been tried or recommended:

  • 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. 

  • Does your child have an Autism Spectrum Disorder (ASD) diagnosis?*

  •  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

     

  • I would like to register for FFS while seeking an ASD diagnosis
  • Are you registered for the Ontario Autism Program (OAP) through AccessOAP?
  • Have you completed or are in the process of completing your Determination of Needs assessment with AccessOAP?

  •  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

     

  • What services are you requesting? (check all that apply)

  • 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
  • What areas of development are impacted - check all that apply
  • What assessments or investigations have been done so far (please include results)
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  • Are any other referrals pending for developmental or mental health supports?*

  • 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

  • Do you agree with the referral to Developmental Resources for Infants?*

  • 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
  • Has your child been seen by a vision care specialist?*
  • If yes, please select
  • Do you provide TVCC with consent to communicate with the above-named vision care specialists and acquire a copy of any available vision reports?
  • Hearing concerns:*
  • Is your child followed by any other specialist/clinician (SLP/OT/PT, Neurology, etc.)*
  • Does your child wear glasses*
  • Does you child make eye contact*
  • Does your child visually notice and/or follow a moving object with the eyes*
  • Does your child tilt or turn head when looking at objects*
  • Does your child squint, close or cover one eye when looking at objects*
  • Does you child blink or squint excessively*
  • Does your child rub or touch the eyes excessively*
  • Does your child avoid or demonstrate sensitivity to bright lights*
  • Does your child notice lights, stare at lights, move towards/reach for lights*
  • Does your child identify colours*
  • Does your child move independently (i.e., creep, crawl, cruise or walk supported or walk unsupported)*
  • Have you noticed your child bumping into things or tripping (carpets, elevation changes, family pets, stairs, curbs, etc.)

  • 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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