Connections for Students Interest Form Home | Connections for Students Interest Form CFS Referral Form Caregiver Name:* First Last Caregiver Phone Number:*Caregiver Email:* Location (City/Town):*Does your child have a diagnosis of autism?* Yes No Is your child currently registered in the Ontario Autism Program (OAP)?* Yes No Student Name:* First Last Student Date of Birth (MM/DD/YYYY):*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920School Name:*School Board:*Current Grade:*Current School Placement:* Mainstream (no support) Mainstream (with support) Part-time learning centre Community/county - Autism Spectrum Disorder (ASD) Community/county - developmental disabilities Is the student currently attending school?* Yes - full time Yes - modified days Not consistently Not at all at this time Please describe any challenges or barriers with the current school placement:*Does the student need any support with transitions at school?* From a service (e.g. ABA, URS) into school From home to school or vice versa From one classroom/space to another at school From one activity to another From one placement to another No transition supports required Other Please describe:Is the student engaging in any challenging behaviours at school?* Aggression (e.g. hitting, kicking) Self-injury (hurting themselves) Elopement (running away) Property destruction (e.g. breaking furniture, ripping books) Other None Please describe the behaviours below:What is your primary goal for the CFS service?* Support with transition needs as specified above Support with behavioural needs Support with transitioning student back to school 1:1 support within the classroom Advocacy around school placement Support with academic goals Referred by:* Service provider (please specify below) School/School board Self-referral Kinark (please provide clinican's name below) Please enter the name of the service provider who referred you to this service:Name of referring Kinark clinician:Acknowledgement* *I understand that CFS is a consultative service that provides recommendations and strategies to school teams. This service is not direct support for the student within the school setting.Consent By completing this form, you certify that you are the primary caregiver of the child/youth which this form is being completed for. If you are not the primary caregiver, you confirm to have consent from the primary caregiver to complete this form. If you are not the primary caregiver or do not have consent from the primary caregiver and are looking to inquire about our services, please complete our 'Request a Free Consultation' form.CAPTCHA
