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


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

Plexus- A Network of FASD Supports and Services in our Community: Client Referral Form

Please complete this form to make a referral to Plexus. We offer a network of FASD supports and services in our Community. These include service coordination, assessment, FASD specific day treatment, support groups and recreational opportunities.

Eligibility:

The services of the Plexus team are available to children, youth and families living with (potential) FASD up until the age of 18 or 21 and still attending school. You must reside in the Waterloo Region.

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

The consent of individuals 16 years of age or older who can 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 FASD Coordinators.

What Happens Next?

After receiving a completed referral form and the required supporting documentation, you will receive a phone call or email from one of our FASD Coordinators

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

Self-Referral
Please tell us how we can help you
:
Please tell us who you are
Salutation:
* First Name:
Middle Name:
Last Name:
Preferred Name:
Date of Birth:
Select Date
Age:
Gender:
Please tell us how we can contact you
Preferred Language:
Please include the area code with phone number.
You can provide additional details to the phone number provided in the adjacent comments box.
Home/Main Phone:
Permission to Call?
Yes
No
Leave a Message?
Yes
No
Comments:
Work Phone:
Permission to Call?
Yes
No
Leave a Message?
Yes
No
Comments:
Alternate Phone:
Permission to Call?
Yes
No
Leave a Message?
Yes
No
Comments:
Email Address:
Address:
:
City:
Province:
Country:
Postal Code:
What is your mother tongue?
If your mother tongue is neither English nor French, in which of Canada's official languages are you most comfortable?
Additional Information (Optional)
What is your marital status?
Do you have children at home? If yes, how many?
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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All information is protected under Ontario privacy legislation and is kept confidential.