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Bridging Abilities Referral Form
By completing this form, you agree to put your child on our waitlist. You understand that there is a wait for services and we will contact you as soon as service providers become available to work with you.
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* Indicates required question
Email
*
Your email
parent/guardian name
*
Your answer
cell phone number
*
Your answer
When we are able to work with you, how would you like us to inform you?
*
email
text message
What community do you live in?
*
Your answer
What language(s) do you speak at home?
*
Your answer
child's age
*
Your answer
child's gender
*
female
male
diagnosis
*
Autism Spectrum Disorder
Cerebral Palsy
Down Syndrome
Attention Deficit (Hyperactivity) Disorder
Global Developmental Delay
Learning Disability
Other:
Required
Is your child attending school/daycare? If so, where?
*
Your answer
How do you plan to pay for services?
*
FSCD. specialized services contract (SS - 12 months)
FSCD, developmental behavioural support contract (DBS - 6 months)
private pay (i.e. insurance or out of pocket)
Which services does your child need?
*
coordination
psychologist/behaviour consultant
speech language pathologist (SLP)
occupational therapist (OT)
physiotherapist (PT)
behavioural/developmental aide
Other:
Required
Please tell us the areas you need support with (e.g. behaviours, communication, emotional regulations, sensory regulation, feeding, fine motor skills, etc.)
*
Your answer
When are you and your child available for therapy during the school year? Please be as specific as possible (e.g., Monday to Thursday 3-7, Friday 1-7)
*Please note that these times are not guaranteed and may be subject to a wait list
*
Your answer
How did you hear about us?
*
Your answer
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