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Sunbeam Developmental Resource Centre
205-1120 Victoria Street North
Kitchener  Ontario  N2B 3T2


Phone: (519) 741-1121,
Fax: (519) 743-4730

Sunbeam Developmental Resource Center Waterloo Region: Client Referral Form

Please complete this form to make a referral to Sunbeam Developmental Resource Centre. We offer clinical assessment, consultation and support services to individuals who have a developmental disability and/or an autism spectrum disorder, and to their family and support agencies. There is no fee for the individual user.

Eligibility:

The services of Sunbeam Developmental Resource Centre team are available to individuals of any age who have a developmental disability and/or an autism spectrum disorder.

A referral can be made by the individual or their legal guardian. SDRC will also accept referrals from extended family members, family physician, or any agency acting on the individual’s/family’s behalf as long as permission to do so has been provided by the individual or their guardian.

The consent of individuals 16 years of age or older who are able to understand the implications of assessment/treatment is required when facilitating a referral on their behalf.

If you have concerns or questions about our agency’s policies regarding eligibility for children, under 18 years of age, please contact our Clinical Intake Worker. Eligibility for adults, 18 years or older, is determined by Developmental Services Ontario.

What Happens Next?

After receiving a completed referral form and the required supporting documentation verifying eligibility for SDRC services, you will receive a Referral Confirmation letter by mail or email within 2 to 4 weeks. This will be followed by contact from an Intake worker to arrange an initial Intake Appointment. The wait for an appointment can vary depending on referral volumes and may take up to 4-6 months.

If you have not received a Referral Confirmation letter from us after 4 weeks, please call 519-741-1121, so that we can avoid any unnecessary delays.

Thank you for your referral to our agency. We look forward to working with you.

Referral ID
Client/Patient Information
Salutation:
First Name:
Middle Name:
Last Name:
   
Alias/Last Name at Birth:
Preferred Name:
DOB:
Select Date
Age: 0
Gender:
Address
Address:
City:
Province:
Country:
Postal Code:
LHIN:
Location/County:
Reserve Client Resides On:
Permission to send mail:
Yes
No
Mailing Address is different:
Contact Information
Primary Preferred Language:
PDS Additional Preferred Languages:
please select all additional languages the client prefers, optional if applicable
Select All | Unselect All
Ctrl-click to select multiple
Phone (Home/Main):
Permission to Call?
Yes
No
Comments:
Phone (Alt):
Permission to Call?
Yes
No
Comments:
Consent to Share Data Electronically:
Yes
No
Email:
Permission to contact via Email:
Yes
No
Preferred communication method:
Other:
Permission to send PREMs survey:
Yes
No
Preferred survey method:
Parents Information
Reset
Parent Name:
Relation:
Pronoun:
Use Client Phone Numbers
Preferred Language:
Phone (Main):
Permission to Call?
Yes
No
Comments:
Phone (Alt):
Permission to Call?
Yes
No
Comments:
Phone (Alt):
Permission to Call?
Yes
No
Comments:
Email:
Permission to contact via Email:
Yes
No
Other Email:
Permission to contact via Email:
Yes
No
Permission to send PREMs survey:
Yes
No
Preferred survey method:
Preferred communication method:
 
Use Client Address
Address:
City:
Province:
Country:
Postal Code:
Permission to send mail:
Yes
No
Reset
Parent Name:
Relation:
Pronoun:
Use Client Phone Numbers
Preferred Language:
Phone (Main):
Permission to Call?
Yes
No
Comments:
Phone (Alt):
Permission to Call?
Yes
No
Comments:
Phone (Alt):
Permission to Call?
Yes
No
Comments:
Email:
Permission to contact via Email:
Yes
No
Other Email:
Permission to contact via Email:
Yes
No
Permission to send PREMs survey:
Yes
No
Preferred survey method:
Preferred communication method:
 
Use Client Address
Address:
City:
Province:
Country:
Postal Code:
Permission to send mail:
Yes
No
Additional Information
Place of Birth:
Marital Status:
Pregnancy Status:
Children in the Home: Number of Children:
Highest Level of Education:
Military Status:
Violence Conviction:
PDS Personal Income Source:
PDS Total Household Income:
PDS Number of People Income Supports:
PDS Housing Status:
PDS Employment Status:
PDS Legal Status:
Select All | Unselect All
Ctrl-click to select multiple
Medical (M) Score:
Behavioral (B) Score:
Culture and Language
Indigenous Status:
Identifies as Urban Indigenous:
If First Nations people, do you have a registered Status:
Status Number:
First Nation Community: Search
Citizenship Status:
PDS Born in Canada?:
Date Came to Canada:
Select Date Clear Date
MCCSS Cultural Identity
Select all that apply
or
Primary Ethnicity:
Cultural Identity
PDS Additional Ethnicity:
please select all additional ethnicities the client prefers, optional if applicable
Select All | Unselect All
Ctrl-click to select multiple
Primary Religion/Spiritual Affiliation Identification:
PDS Additional Religion and Spiritual Affiliation:
please select all additional religions the client prefers, optional if applicable
Select All | Unselect All
Ctrl-click to select multiple
Primary Mother Tongue/First Language:
PDS Additional Mother Tongue/First Language(s):
please select all additional languages the client prefers, optional if applicable
Select All | Unselect All
Ctrl-click to select multiple
If mother tongue is neither French nor English, in which of Canada's official languages is the client most comfortable?
Language Interpreter required:
Comments:
Primary Contact/Parent/Legal Guardian
Reset
Next of Kin Name:
Relation:
Pronoun:
Use Client Phone Numbers
Preferred Language:
Phone (Main):
Permission to Call?
Yes
No
Comments:
Phone (Alt):
Permission to Call?
Yes
No
Comments:
Phone (Alt):
Permission to Call?
Yes
No
Comments:
Email:
Permission to contact via Email:
Yes
No
Other Email:
Permission to contact via Email:
Yes
No
Permission to send PREMs survey:
Yes
No
Preferred survey method:
Preferred communication method:
 
Use Client Address
Address:
City:
Province:
Country:
Postal Code:
Permission to send mail:
Yes
No
Other Contacts
Select type:
Hide/ShowConsent (if child is 16 years of age or older)
Client (if 16 years of age or older) is aware of and has consented to this referral to SDRC. If No, Referral can not be accepted:
Referring Agency/Primary Care Information
Agency/Source Name:
Agency/Referral Source Type:
Contact Name (if differs from the Agency/Source Name):
Category:
So that we can add you in our address book
Phone:
Phone (Alt):
Phone (Alt):
Fax:
Email:
Website:
 
Address:
City:
Province:
Country:
Postal Code:
Referral Information
Reason(s) for the referral
Presenting Issues:
Accessing SDRC Services
  
Risk Factors
PDS Pre-Existing Conditions:
Select All | Unselect All
Ctrl-click to select multiple
Harm to Self:
Harm to Others:
Unable to Care for Self:
Financially Vulnerable:
Legal Issues:
Substance Use:
Serious Medical Conditions/Chronic Illness:
Other Risk Factors:
Risk Factor Details:
Mental Health Information
Primary Diagnosis:
Additional Diagnoses:
Select All
Ctrl-click to select multiple
Other Illness Information:
Select All
Ctrl-click to select multiple
First Agency Contact:
Select Date Clear Date
First Hospitalization:
Select Date Clear Date
First Diagnosis of Mental Illness:
Select Date Clear Date
Comments:
Medical Conditions
   
Medical Information
Medical Exams:
Last Dental Date:
Select Date Clear Date
Temperament:
Hearing Problems:
 
Other - specify:
Vision Problems:
     
Other - specify:
Sensory Concern:
     
Other - specify:
Medical Condition/Special Needs:
Physical Traits
Height:
Weight:
Height/Weight Date:
Select Date Clear Date
Height/Weight Comment:
Eye Colour:
Hair Colour:
Distinguishing Marks:
Allergies
Animal Saliva
  
Aspirin
 
Bee Stings
Chromium
  
Cigarette Smoke
 
Drug Allergy
Eggs
  
Fish
 
Grasses
Hayfever
  
House Dust
 
Household Cleaners
Latex
  
Milk
 
Mold
Nickel
  
No known diagnosed allergies
 
None
Other
  
Peanuts
 
Peas
Penicillin
  
Pet Dander
 
Poison Ivy
Pollen
  
Preservatives (Creams, Ointments & Cosmetics)
 
Ragweed
Rubber Products
  
Shell Fish
 
Soy
Sulfa
  
Trees
 
Weeds
Wheat
  
Medication
Active Medication:
Hide/ShowPlease indicate all supports/programs currently being accessed/referred to
Disability Tax Credit:
Assistance for Children with Severe Disabilities:
Special Services at Home:
Ontario Autism Program:
Access2 Card:
PAL Card:
GRT Support Person Card:
Disability Travel Card:
Easter Seals Incontinence Grant:
KidsAbility:
KW Habilitation:
Front Door/Carizon:
Hide/ShowREFERRAL SOURCE (if other than parent)
Client/Parent/Guardian Permission Received to Facilitate this Referral? If No, Referral can not be accepted.
Yes
No
Hide/ShowFor Referral Facilitated by KidsAbility
Resource Support only referral (For children aged 3 and under):
(If yes, child will be registered with SDRC and family is to contact SDRC for Resource Support when needing help)
Attachments
1. If you would also like to make a referral for services from Sunbeam Developmental Resource Centre, please upload documentation that provides an assessment letter/report regarding a diagnosis of an Autism Spectrum Disorder and/or an Intellectual Disability. A letter simply stating a diagnosis without providing supporting assessment information is not sufficient to confirm eligibility for SDRC services.

2. For referrals to Plexus Network of FASD Supports and Services, referrals can be made with or without a diagnosis of FASD.

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2025-05-21T07:29:02-04:00
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