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Date:____________________Howdidyoulearnaboutourservices?__________________________________
PersoncompletingForm:_____________________Whatserviceareyouinterestedin?
Centre-basedABA Home-basedABA AfterschoolABA ParentingTraining BehaviouralConsultation
CLIENTINFORMATION:Name:_______________________________D.O.B____________Age______Gender: M F Other
Address:________________________________________City:________________PostalCode:___________
HealthCard#:________________________________________VersionCode:__________________
Doesyourchildhaveadiagnosisorexceptionality?(ifyes,pleaseidentify)______________________________
Ageofdiagnosis:______________
PARENT/GUARDIANINFORMATION:Name:____________________________________________RelationshiptoChild:______________________
D.O.B:______________________(Age)_______Gender: M F Other
MainContact#:_________________________________Alternate:__________________________________
Address: SameasaboveOR_____________________________City:____________PostalCode:________
Doyouhaveadiagnosisorexceptionality?_______________________________________________________
Doyouhaveafamilyhistoryofmentalorphysicalhealthconcerns?__________________________________
Married Common-law Separated Divorced Widowed-Pleaseindicatedate:_________or Single
ABASERVICESINTAKE-UNDER18
Isyourchild/youthandfamilyregisteredwiththeOntarioAutismProgram(OAP)? Yes No
Ifno,areyouchoosingtopayprivatelyforservices? Yes No
Ifyes,pleasespecify:
WehaveselectedDFO WearecurrentlyonthewaitlistforOAPservicesWearecurrentlyreceivingOAPservicesbutwishtochangeproviders
OAPFamilyServiceWorkerInformation(ifregisteredwithOAP):
Name:___________________________________________
PhoneNumber:____________________________________
Email:____________________________________________
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Email*(Wewilluseemailforimportantcorrespondence):__________________________________________PleaseaddmetoyourmaillistsothatIreceiveinformationaboutprogramsandservices: Yes No
PARENT/GUARDIAN2INFORMATION:Name:____________________________________________RelationshiptoChild:______________________
D.O.B:______________________(Age)_______Gender: M F Other
MainPhone#:__________________________________Alternate:__________________________________
Address: SameasaboveOR_____________________________City:____________PostalCode:________
Doyouhaveadiagnosisorexceptionality?_______________________________________________________
Doyouhaveafamilyhistoryofmentalhealthorphysicalconcerns?__________________________________MaritalStatus:
Married Common-law Separated Divorced Widowed-Pleaseindicatedate:_________or Single
Email*(Wewilluseemailforimportantcorrespondence):__________________________________________PleaseaddmetoyourmaillistsothatIreceiveinformationaboutprogramsandservices: Yes No
CHILDCUSTODY:Joint Sole Ifsole,withwhom?________________(Ifsolecustody,wemustreceivecourtorder)Isthischild:Natural Adopted Foster ____Dateofplacement/adoption:_______________________EMERGENCYCONTACTS(otherthanparent):Name:____________________________________________RelationshiptoChild:______________________
Maincontact#()____________________________Alternate#()_____________________________
Name:____________________________________________RelationshiptoChild:______________________
Maincontact#()____________________________Alternate#()_____________________________
Previous/currentcontactwithMentalHealthProfessionalsorSupportServices:
NameofAgency ProfessionalInvolved TypeofSupport(medication,
counselling,etc.).
DateandDurationofTreatment
Wasiteffective?
Areyoucurrentlyonanywaitlistsforservices?:_________________________________________________
HowfamiliarareyouwithwhatABAservicesentail? Veryfamiliar Somewhatfamiliar Notatallfamiliar
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FamilyContacts Biological Step/Half Adoptive Foster/GuardianParent/Guardian□M□F□Other
Name(age)
Name(age) Name(age) Name(age)
Phone
Phone Phone Phone
Work/Occupation
Work/Occupation Work/Occupation Work/Occupation
Parent/Guardian□M□F□Other
Name(age)
Name(age) Name(age) Name(age)
Phone
Phone Phone Phone
Work/Occupation
Work/Occupation Work/Occupation Work/Occupation
Sibling1□M□F□Other
Name(age)
Name(age) Name(age) Name(age)
Sibling2□M□F□Other
Name(age)
Name(age) Name(age) Name(age)
Sibling3□M□F□Other
Name(age)
Name(age) Name(age) Name(age)
Sibling4□M□F□Other
Name(age)
Name(age) Name(age) Name(age)
Sibling5□M□F□Other
Name(age)
Name(age) Name(age) Name(age)
Sibling6□M□F□Other
Name(age)
Name(age) Name(age) Name(age)
Wholivesinthehome(names,relationshipandages)?Doanysiblingsorcousinshaveadiagnosisorexceptionality?Ifyes,whatageweretheydiagnosed.Ifchildlivesinmorethanonehomepleaseprovidedetailsonlivingarrangements?CHILD’SEDUCATION:NameofSchool:__________________________________SchoolBoard:_____________________________
SpecialEducationClass IEP(IndividualizedEducationPlan) ResourcePeriodEducationalAssistance Tutoring Other
Pleaseattachmostrecentcopyofyourchild’sIEP
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CHILD'SDEVELOPMENTALHISTORY: PrenatalandBirthEvents:Pregnancycomplications?(bleeding,excessvomiting,medication,infections,x-rays,smoking,alcohol/druguseetc.) DeliveryComplications? ToiletTraining:(AgeReached)BowelControl:DayNightBladderControl:DayNight CurrentConcerns/Goals: SexualDevelopment/Genderidentity: CurrentConcerns/Goals: MotorDevelopment:(Pleasedescribeanyconcernsorgoalsforyourchild’smotorskilldevelopment) Doesyourchildfavourahandwhenwriting,orafootwhenplayingsports(e.g.,kicking)? LanguageDevelopment:(pleasedescribeanyconcernsorgoalsforyourchild’slanguagedevelopment) SocialDevelopment:(pleasedescribeanyconcernsorgoalsforyourchild’ssocialdevelopment) Currentpeerinteractions: Specialinterests/hobbies:
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EATINGBEHAVIOURS:Eatshealthyfoods: Yes No Eatsmostlyjunkfood: Yes NoOver-eats: Yes No Doesnoteatenough: Yes NoFeeding: Orallyfed G-tubefed YesGJ-tubefedDifficultyswallowingfoods(i.e.maycough,gag,vomitduringorbetweenmeals): Yes NoIfyespleaseexplain,______________________________________Gagswhennewfoodsareintroduced: Yes No
Drinksliquidfrom: Sippycup Bottle RegularCupHaschallengesdrinkingliquids: Yes NoTypesofliquidsconsumed:__________________
Exhibitsinappropriatebehavioursatmealtimes: Yes NoIfyes,pleaseexplain:________________________________________________________________________DietaryRequirements(selectallthatapply):
Regular,dietastoleratedLactose-IntolerantVegetarian:
Semi-Vegetarian(nobeeforpork) Lacto-Ovo(nobeef,pork,chicken,seafood,orfish) Vegan(nomeats,eggs,ordairy) Other-Pleasespecify:__________________________________
GlutenFreedietPickyEater(pleaseexplain):______________________________________________Otherfoodrestrictions:___________________________________________________________________
SLEEPBEHAVIOR:Hasaconsistentbedtimeroutine Yes NoBedtime:_________Wake-time:_________Goestobedandfallsasleepwithnodelay: Yes NoIfyes,pleaseexplain:________________________Fallsasleepwithoutassistance: Yes NoFallsasleepwithassistanceofcaregiver/parent: Yes NoRemainsasleepthroughoutthenight: Yes NoWakesupseveraltimes: Yes NoIfyes,howmanytimes?____________________________________Pleasedescribehowtogetyourchildtofallbackasleep:____________________________________________Pleasedescribewhatyourchilddoesifhe/shewakesupinthemiddleofthenight:__________________________________________________________________________________________Napsduringtheday Yes NoNaptime:_________Duration:_________
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PROBLEMBEHAVIOURINFORMATIONProblemBehaviour(Describewhatyourchilddoes/says)
Frequency(hourly,daily,weekly)
Duration(howlongthebehaviorlasts)
SeverityMild–disruptivebutlittleriskModerate–somewhatsignificantdamage.Severe–verysignificantthreattohealthorsafety
Describehowyourchildcalmsdown
Isthecalmingtechniqueeffectivebothshortandlongterm?
Pleasedescribethesituationsthattheseproblembehavioursaremostlikelytooccur:________________________________________________________________________________________________________________________________________________________________________________________________________Pleasedescribethesituationsthatthebehavioursareleastlikelytooccur:_________________________________________________________________________________________________________________________________________________________________________________________________________________Pleaselistthetechniquesimplementedinthepasttodecreaseproblembehavioroccurrences:______________________________________________________________________________________________________Pleasedescribehowyourchildrequestsforitems:__________________________________________________________________________________________________________________________________________Pleasedescribeyourchild’sabilitytoanswerquestions:____________________________________________
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CHILD’SMOOD:Howwouldyoudescribeyourchild’spersonality? Doesyourchildhaveanyfears/phobias? Yes NoIfyes,pleasedescribe: Howdoesyourchildexpresstheirfeelings?:
CHILD'SHEALTHINFORMATIONANDHISTORY:AnaphylacticAllergies:
Doesyourchildhaveanylifethreateningallergies? Yes No
Ifyes,pleaselisttheanaphylacticallergies:______________________________________________________
Typeofauto-injector:EpiPen: Junior AdultAllerject: Junior Adult
Ifyourchildhasalife-threateningallergyyouMUSTcompletetheANAPHYLAXISEMERGENCYPLANFORMANDADMINISTRATIONOFMEDICATIONFORM. AllOtherAllergies:Doesyourchildhaveanynonlife-threateningallergies? Yes No
Ifyes,pleasecompleteinformationbelow:
Allergy:Drugs/Food/Environment
ReactionorSymptoms:AllergyorSideEffect
RecommendedResponse
Doyouadministermedicationforallergicreactions? Yes No
Ifyes,pleasecompletetheADMINISTRATIONOFMEDICATIONFORM.
HealthConditionsorComplications:
Doesyourchildhaveanycurrenthealthcomplicationsorconditions?
Ifyes,pleaseexplain:
_________________________________________________________________________________________
__________________________________________________________________________________________
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MEDICATIONS–CURRENT
PASTMEDICALHISTORY: No Yes1. MAJORILLNESSES Year Illness Treatment Result
No Yes2. SURGERY Year TypeofSurgery ReasonforSurgery Result
No Yes3. HOSPITALIZATIONS Year Illness Treatment Result
OtherHealthIssues(checkallthatapply):Asthma Arthritis BowelIssues BleedingDisorder
Concussion:Date:_________
Diabetes ChronicEarInfections EarTubes
ChronicNoseBleeds
FrequentColds HeartCondition Headaches
HearingDifficulties HearingAids HighBloodPressure SeizuresSight/VisionDifficulties SinusTrouble SkinConditions/Rashes ToothachesOther:
_____________________Other:
__________________Other:
_____________________Other:
__________________
NameofMedication Dosage #Times/day OtherDirections:
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No Yes4. INJURIES/ACCIDENTS Year Injury
No Yes5. PHYSICAL/SEXUALABUSE Year RelevantInformation
IMPORTANTINFORMATION:Pleasedescribeyourchild’sstrengthsandinterests(extracurricularactivities,hobbies,thingstheyenjoy):
Whatareyourgoalsforyourchild/Whatareyouhopingtoachieve?
Pleasedescribeanystressors/triggersandwhenyourchildisexperiencingdifficulties:
Pleasedescribeyourchild’smostpreferitems/activitiesPleasedescribeyourchild’sleastpreferreditems/activities
Isthereanythingelseyouwouldlikeustoknow?
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Pleasecheckanyareasofconcernthatapplyandprovidedetails
☐Delaysinfinemotorskills(printing,grippingitems,usingscissors)____________________________________________________________________________________________________________________________ ☐Dailyliving/self-careskills(dressing,toileting,hygiene,eating)______________________________________________________________________________________________________________________________ ☐ Sensoryprocessingchallenges(overly/undersensitive)____________________________________________________________________________________________________________________________________ ☐Grossmotorskills(handeyecoordination,balance)_____________________________________________________________________________________________________________________________________ ☐Anxiety,depressionormentalhealthchallenges__________________________________________________________________________________________________________________________________________ ☐ Schoolperformance(attention,organization,remainingseated,academicdifficulties)___________________________________________________________________________________________________________ ☐ Socialskills(maintainingrelationships,socialboundaries,initiatingconversation)_______________________________________________________________________________________________________________ ☐ Communication(languagedelays,currentlyusingcommunicationtools)____________________________ __________________________________________________________________________________________ ☐Family/siblingrelationships_________________________________________________________________☐Regulationofemotions/irregularmood________________________________________________________ ☐ Developmental/Learningdelays______________________________________________________________________________________________________________________________________________________
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ThankyouforyourinterestinIntegrateHealthServices.Pleasebeawarethatallclientinformationwillbestoredasconfidentialclinicrecords.Whereassessmentservicesareprovided,informationsharedwillbecomepartofaconsultletter,whichwillbeforwardedtotheclientand/orparent(s)/guardian(s)andreferringphysician.Anyadditionalinformationsharedoutsidetheclinicwouldrequirethewrittenpermissionoftheclientorparent(s)/guardian(s)(whentheclientisundertheageof16orunabletoprovideconsent).CONFIDENTIALITY:Therearebylaw,certaincircumstancesinwhichconfidentialitycannotbemaintained.Thesesituationswould include: (1) suspectedchildabuseorneglect (2)circumstanceswhere theclienthasbecomeadangertothemselvesorothers,(3)wheninformationhasbeensubpoenaedbythecourt.Shouldyouhaveanyquestionsaboutthe limitsofconfidentiality,pleasecontactan IntegrateHealthServicesteammember.PARENTALCONSENT:All childrenunder16 yearsof age requireparental/guardian consent to access services at IntegrateHealthServices.Clientsovertheageof16(whoarebelievedtobecapableofunderstandingthedetailsofinformedconsent)areabletosigntheirownconsentforservices.APPOINTMENTS:Pleaseensureyouarriveontimeforyourscheduledappointment,asweareunabletoextendyoursessiontime.Noshowappointmentswillbesubjecttoahalf-sessioncharge.WAIVER:Mychild'sphotograph/visuallikenessmaybedisplayedatIntegrateHealthServicesoffice(forthepurposesofclientawards/recognition).Igiveconsent☐Idonotgiveconsent☐INTEGRATEHEALTHSERVICESTEAMAPPROACH-CIRCLEOFCARE:Integrate Health Services is a multi-disciplinary team working in partnership with The Kids Clinic. We arecomprisedofvarioushealthprofessionalsandincircumstanceswhereitisbelievedtobeinthebestinterestoftheclient,pleasebeawarethatpersonalhealthinformationmaybesharedamonghealthcareprovidersatIntegrate Health Services and Kids Clinic. Information shared will be determined on a case-by-case basisdependant upon the needs of the individual client(s). *When you access Speech Therapy or OccupationalTherapyServices,pleasebeawarethattheinformationyouprovidetoIntegrateHealthServicesissharedwithourpartners,SpeechTherapyCentresofCanadaandAshleyRegoOccupationalTherapyServices.Bysigningthis form, you are consenting to all services provided through Integrate Health Services, includingthoseaffiliatedwithSpeechTherapyCentresofCanadaandAshleyRegoOccupationalTherapyServicesandunderstandthatthesamelimitsofconfidentialityapply.
INFORMEDCONSENT
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CONFIDENTIALITYWITHCHILDREN:Inorderforchildrenandadolescentstofeelsafeandbeabletoidentifyanddiscussconcerns,theymustfeelasense of privacy and some control over the information they share. At Integrate Health Services, it is ourresponsibilitytohonourandrespectthechildoradolescent’sconfidentiality-thisiscrucialtodevelopingtrustandachievingpositiveoutcomes.Weunderstandthatparent(s)/guardian(s)wanttobeupdatedregardingtheassessment/counselling process and be made aware of any information that would assist them in bettersupporting their child/adolescent. We will always seek permission from the child / adolescent to sharerelevantthemesordetailswhereitisdeterminedtobeintheirbestinteresttodoso.Ifotherfamilymembersmayparticipateincounsellingsessions,pleaselistthembelow:
Name RelationshipDateofBirth
1._____________________________ _________________________________________________2._____________________________ _________________________________________________3._____________________________ _________________________________________________
IntegrateHealthServicesprovidesthefollowingsupportprogramsandservices:
• PsychologicalAssessments• CounsellingServices• ArtTherapy• BehaviouralTherapy-AppliedBehaviourAnalysis(ComprehensiveandFocusedABA)• BehaviourConsultation• Child/Youth/AdolescentGroupPrograms• ParentSupportandSkillsTraining• EducationServices• SpeechandLanguageTherapy(throughourpartnershipwithspeechtherapycentresofCanada)• Occupational Therapy Services (through our partnership with Ashley Rego Occupational Therapy
Services)
I, ___________________________________________________________________ have reviewed the aboveinformation and fully understand the details of informed consent. An Integrate Health Services team member hasansweredanyquestionsIhad.Atthistime,Imakeaninformedchoice(formyselforchild)toaccessservicesatIntegrateHealthServices.*PleaseNote:Childrenenrolling inagroupprogrammusthave theability tomanage ina3:1or4:1ratio (dependantuponprogram). Ifyouhaveconcernsaboutsuitabilityorwould liketodiscussoptions foradditionalsupport,pleasecontactus.___________________________________ ______________________________ _____________________ClientName Signature(ifover16) Date
CLIENTCONSENT:
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Iftheclientisunder16years,parent/guardianconsentisrequired(BOTHparentsinthecaseofajointcustody)
____________________________________________________________ _______________________Parent/GuardianName Signature Date
____________________________________________________________ _______________________Parent/GuardianName Signature Date
____________________________________________________________ _______________________WitnessName WitnessSignature Date
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*Tobecompletedforclientundertheageof16priortoaccessingservicesifparentsareseparatedordivorced
ThankyouforaccessingservicesatKidsClinic/IntegrateHealthServices.Pleasebeawarethatallchildrenundertheageof16requireparental/guardianconsenttoaccessservices.Insituationsinwhichparents/guardiansareseparatedordivorcedandthere is jointcustody(even if thechild livesonlywithoneparent),bothparentsmustprovidesignedconsentbeforeachildcanaccessservices.
It is my/our understanding that accessing services are intended to support my/our child’s overall well-being. Thepurposeofaccessing these services is tobenefit thechild involvedandnot to collectorgather information for courtpurposes. *It isparent’sresponsibilitytoadvisetheclinicofanychangestochildcustody,accessto information,etc.andtoprovidethesupportingdocumentation.
_____________________________________________________________ ________________Parent/GuardianName SignatureDate
_____________________________________________________________ ________________Parent/GuardianName SignatureDate
_____________________________________________________________ ________________
Parent/GuardianName WitnessSignatureDate
InCircumstancesofSoleCustody:I,(parent/guardianname)_______________________________________________beingthesolecustodialparentofchild’sname_______________________________________________________,D.O.B.:________________________ herebyconsenttoassessmentorsupportservicesforthischild,atKidsClinic/IntegrateHealthServices.Isthereacurrentcourtorderregardingcustody/accessforthischild� Yes� No(thismustbeprovidedtoclinic)Doestheagreementallownon-custodialparentaccesstoinformation?� Yes� NoThiscustodialarrangementis:☐Permanentdisposition☐Interimdispositionuntil(date)________________________
InCircumstancesofJointCustody:I,_____________________________________________and______________________________________________parent/guardiannameparent/guardiannamebeingjointcustodialparents/guardiansof(child’sname)_________________________________________________, D.O.B.: __________________ hereby consent to assessment support services for this child, at Kids Clinic/IntegrateHealthServices.
PARENTALCONSENT(CustodyAgreement)