Resource Kit Request Form

* indicates required field
Child/Youth First Name*
Child/Youth Last Name*
Child/Youth Date of Birth*
City/Town*
Parent First Name*
Parent Last Name*
Email*
Phone Number*
Preferred Contact Method:
- E-mail
- Phone
Language Preference*
Is your child currently registered in the Ontario Autism Program? Please note that if you are not registered, you can still receive an Individualized Resource Kit.*
- Yes
- No
Please specify your relationship to the child/youth (i.e. parent/guardian, service provider, etc.)*
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 contact our Service Representative at 1-800-283-3377.
Child/Youth Profile
To help us prepare materials for your child, please complete the below section.
Communication (please select one that best describes your child/youth):*
- Speaks fluently in full sentences and can discuss events that happen in the past or future
- Speaks in full sentences but may need support with extended discussions or reciprocal conversations
- Speaks in two or three word phrases
- Uses an alternative communication (e.g., sign language, picture exchange communication system, communication device)
- Has no formal mode of communication (e.g., cries, pulls, points, pushes)
Written communication (please select one that best describes your child/youth):*
- Can read written words at their grade level 
- Can read simple words
- Can understand that picture depictions represent an item (e.g., a clip art picture of a lunch bag indicates “lunch”)
- Will need photographs or objects to represent items/activities in a resource
What types of resources are you looking for? (Please select one):*
- Visual Schedules – used to show your child a sequence of events using pictures, objects or written words. (e.g., daily, morning, or afternoon schedules; handwashing, dressing, toothbrushing, and homework schedules.)
- Token Boards – a reward system for your child.
- Choice Boards – shows your child pictures of different items that are available to them to help them make choices.
- First-then Board – provides information to your child around a task expectation and what will follow, to increase their motivation to complete a task.
- Social Narratives – a short story that describes appropriate social behaviours or responses to social situations. (e.g., going back to school, supply teacher, greetings)
What are some of your child’s topics of interest or preferred activities?*
Are there any other considerations you would like us to include when developing individualized resources for your child (e.g., physical features, skin tone, gender identity, culture, religion, favourite characters)?*
Please share any additional information or other considerations we should be aware of (e.g., need for interpreter, upcoming changes, cultural or religious considerations).*
Please specify your preferred appointment time (for questions/consultation for an individualized resource kit):*
- Morning
- Afternoon
- Evening
How did you hear about us?*
- Informal networking (e.g., friends, family, support group)
- Physician or other medical professional
- Social media (e.g., Facebook, Twitter)
- Community agency or organization
- Google or other search engine
- Ministry website/letter
- Brochure/flyer/poster
- Online advertisement
- e-Newsletter
Would you like to receive information of Kinark's services and products through email?
- Yes
- No
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Resource Kit Request Form

Child/Youth Profile

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