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

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 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.

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Referral:

Service Provider Referral Form ID

Date:

2025-09-15 18:40

Status:

Draft

Attachment(s):

( Max File Size is 256 MB )

TIP:To select multiple files, hold down the CTRL or SHIFT key while selecting

Attachment Type:

Client/Patient Information

First Name

Last Name

DOB

DOB Estimated

Age

Years Months

Gender

Address Information:

Address Line 1

Address Line 2

City

Location/County

Postal Code

Province

Country

Unit Number:

Contact Information

	Primary Preferred Language
	Is French the child's first language (mother tongue)?
	Does the child/youth identify as Indigenous?
	Client 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)
	Email
	Permission to contact via Email

Additional Information

Culture and Language
	Language Interpreter required:
	Comments:

Primary Contact/Parent/Legal Guardian

	Next of Kin First Name:
	Next of Kin Last Name:
	Relation
	Pronoun:
	Permission to disclose information:
	Primary/Emergency Contact
	Preferred Language
	Client Address Book - Personal Support
	Main Phone
	Comments Main Phone
	Permission to call? Main Phone
	Permission to leave a message? Main Phone
	Permission to text? Main Phone
	Alternate Phone
	Comments Alternate Phone
	Permission to call? Alternate Phone
	Permission to leave a message? Alternate Phone
	Permission to text? Alternate Phone
	Other Alternate Phone
	Comments Other Alternate Phone
	Permission to call? Other Alternate Phone
	Permission to leave a message? Other Alternate Phone
	Permission to text? Other Alternate Phone
	Email
	Permission to contact via Email
	Client Address Book - Personal Support
	Address Line 1
	Address Line 2
	City
	Postal Code
	Province
	Country

Other Contacts

	First Name:
	Last Name:
	Relation
	Pronoun:
	Permission to disclose information

	Preferred Language

	Main Phone
	Comments Main Phone
	Permission to call? Main Phone
	Alternate Phone
	Comments Alternate Phone
	Permission to call? Alternate Phone
	Other Alternate Phone
	Comments Other Alternate Phone
	Permission to call? Other Alternate Phone
	Email
	Permission to contact via Email

	Address Line 1
	Address Line 2
	City
	Postal Code
	Province
	Country

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:

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
	Main Phone
	Phone (Alt):
	Phone (Alt):
	Fax
	Email
	Website
	Address:
	Address Line 1
	Address Line 2
	City
	Postal Code
	Province
	Country

Referral Information

Reason(s) for the referral

Please indicate all supports/programs currently being accessed/referred to

REFERRAL SOURCE (if other than parent)

Client/Parent/Guardian Permission Received to Facilitate this Referral? If No, Referral can not be accepted.

Yes

For 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

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.