EMHware :: Sunbeam Developmental Resource Centre

Sunbeam Developmental Resource Centre

205-1120 Victoria Street North

Kitchener Ontario N2B 3T2

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

Referral Type:

New Referral

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Referral:

Parent/Guardian Referral Form ID

Date:

2025-09-15 18:38

Status:

Draft

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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 in the child/youth name 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 in the child/youth name and the required supporting documentation verifying eligibility for SDRC services, you will receive a Referral Confirmation letter by mail or email within 4 to 6 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 6-8 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.

Child/Youth Referral

	Reason(s) for the referral
	Referral Source

Child/Youth Information

First Name

Middle Name

Last Name

DOB

Age

Years Months

Gender

Address:

Unit Number:

City

Postal Code

Does your child/youth identify as Indigenous?

Is French your child's first language (mother tongue)?

Consent (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:

Please tell us who you are and how we can reach you

You must enter a phone number or an email address where you can be reached.

	*Your First Name:
	*Your Last Name:
	*Your relationship to the Child/Youth: Please include the area code with phone number.
	Preferred Language
	Contact Information
	Phone (Home/Main)
	Comments Phone (Home/Main)
	Permission to call? Phone (Home/Main)
	Permission to leave a message? Phone (Home/Main)
	Permission to text? Phone (Home/Main)
	Phone (Alt)
	Comments Phone (Alt)
	Permission to call? Phone (Alt)
	Permission to leave a message? Phone (Alt)
	Permission to text? Phone (Alt)
	Email
	Permission to contact via Email
If applicable, please provide information for a second parent/caregiver:
	* First Name:
	* Last Name:
	* Relationship to the Child/Youth:
	Please include the area code with phone number:
	You can also include details to the phone number provided in the comments box.
	Preferred Language
	Contact Information
	Phone (Home/Main)
	Comments Phone (Home/Main)
	Permission to call? Phone (Home/Main)
	Permission to leave a message? Phone (Home/Main)
	Permission to text? Phone (Home/Main)
	Phone (Alt)
	Comments Phone (Alt)
	Permission to call? Phone (Alt)
	Permission to leave a message? Phone (Alt)
	Permission to text? Phone (Alt)
	Email
	Permission to contact via Email

Attachments

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.

* By sending this form, I allow the agency to contact me.

All information is protected under Ontario privacy legislation and is kept confidential.