York Simcoe Autism Network (YSAN) Ontario Autism Program (OAP) Intake

Date of Referral (MUST NOT BACKDATE):

Client Information

First Name:

Last Name:

Date of Birth:

Street Address:

City:

Province:

Postal Code:

Lived Gender Identity:

Male Female Non-binary Two-spirited Transgender

Ontario Autism Program (OAP) Registration Number:

Does client identify as Indigenous; that is First Nations (North American Indian), Metis or Inuit?

Yes No

School Board:

School:

Parent or Guardian Information

Caregiver #1 First Name:

Last Name:

Relationship to client:

Custody:

Address Same as Client:

Yes No

If no, please specify Home Address:

City:

Province:

Postal Code:

Primary Phone#:

Alternate Phone#:

Email Address:

Primary Language:

Secondary Language:

Interpreter required:

Yes No

French Language Services Required:

Yes No

Caregiver #2 First Name:

Last Name:

Relationship to client:

Custody:

Address Same as Client:

Yes No

If no, please specify Home Address:

City:

Province:

Postal Code:

Primary Phone#:

Alternate Phone#:

Email Address:

Primary Language:

Secondary Language:

Interpreter required:

Yes No

French Language Services Required:

Yes No

Collection and Sharing Consent

If this form is completed by professional, please respond: Youth/Family agree with this referral including the collection and sharing of information for the purposes of processing referral

Please respond:

Yes No

If yes, by whom:

Program Requested

Caregiver-Mediated Early Years (CMEY) Programs:

Yes No

If yes, have you received your invitation?

Yes No

Entry to School (ETS) Program:

Yes No

If yes, have you received your invitation?

Yes No

Foundational Family Services - navigation:

Yes No

Urgent Response Services (URS):

Yes No

Reason for Referral (required for URS):

Referring Person's Information

Referring Person's Name (Provider or Parent/Guardian):

Referring Person's Relation to Client:

Referring Person's Phone:

Referring Person's Email: