Client Funded Clinical Services Services Request Form Foundational Family Services Workshops Virtual Consultation Clinic Other Foundational Services FFS Feedback Form Core Clinical Services ABA (Applied Behavioural Analysis) Mental Health Services Speech-Language Pathology Occupational Therapy Autism Services Feedback Form Entry to School Program PLAY Project Urgent Response Services Other Related Services Respite Services Behaviour Development Program Infant and Child Development Therapeutic Riding Program
Date of Request(Required) MM slash DD slash YYYY Section A:Name(Required) First Last OAP#DOB(Required) MM slash DD slash YYYY AGE(Required)Gender(Required)Address(Required) Street Address City Province Postal Code Diagnosis/Diagnoses(Required)Name of School/DaycareSection B: Parent(s)/Legal GuardianName(Required) First Last Address(if different)Primary Phone(Required)Secondary PhoneEmail(Required) Name First Last Address(if different)Primary PhoneSecondary PhoneEmail Custody(Required) Both Mother Father Other Section C: Service Preference (Select all that apply)Service Preference(Required) Applied Behavior Analysis Individual Service(individual or Group based) Occupational Therapy Speech/Language Services Mental Health Services Psychological Assessments Section D: Current Needs/GoalsWhat are your top three goals for your child? Please be specific.1.(Required)2.3.Section E: Funding and Service FeesWhat is your current situation?(Required) OAP Core Clinical Funding (This means you have had your determination of needs and have received your funding agreement already) you have the financial security to pay for service through personal funds and if required could provide a retainer to be held for services rendered Neither of the above OAP Core Clinical Funding – date of agreement(Required) MM slash DD slash YYYY Would you like more information on how to access funding?(Required) Yes No By completing this form, you are acknowledging that you will be added to the Client Funded Clinical Services email distribution list. Your email address will only be used for the purpose of communicating with you about programs and services and will not be shared with a third party. You will be responsible for monitoring this email distribution list and following the links provided to register for various programs and services as they become available. You can contact us at any time to opt out of the distribution list.
