Service Intake 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?
- Yes
- No
Please specify your relationship to the child/youth (i.e. parent/guardian, service provider, etc.)*
Please specify the services you have accessed through Kinark:*
- Service Navigation
- Parent and Caregiver Education
- Brief Behavioural Consultation
- Support Groups
- Social Time
- Kinark Kreates
- Ask a School Consultant
- Transition to Adulthood
- Ontario Autism Program (OAP) Information Sessions
- Beyond the OAP: Accessing Regional Resources
- Resource Kits
- ABA Services (e.g., IBI)
- ABA Groups (e.g., social skills)
- ABA Coaching
- Assessment Services
- Connections for Students (CFS)
- Social Work
- Not applicable
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.
1. Please indicate the primary reason for the consultation and provide a brief description (if applicable):*
If you were directed to Brief Behavioural Consultation from a Parent Education Workshop, please specify the workshop:
If you are looking for an individualized resource kit, please specify:
2. What are your child's current language skills?*
- Non-Verbal
- Single Words
- Short Sentences
- Full Sentences
- Sign Language
- Uses Gestures/Points
- Other
If "Other", please specify
3. Does your child use an alternative/augmentative communication system?*
- No
- PECS
- Proloquo2GO
- LAMP
- Flip n' Talk
- Other
If "Other", please specify
4. What is your child's current classroom/school placement?*
- Mainstream (no support)
- Mainstream (with support)
- Part-time learning centre
- Small class placement - autism spectrum disorder (ASD)
- Small class placement - developmental disabilities
- Other
If "Other", please specify
5. Please select any other services or supports with which, or professionals with whom your child is currently receiving care:*
- School
- Daycare
- Speech Language Services
- Occupational Therapy
- Behaviour Management Services
- Respite
- Applied Behaviour Analysis (ABA) Services
- Medical/Psychopharmacology
- Mental Health Services
- Not Applicable
6. What strategies have you tried already to address the reasons/concerns you listed above? What has worked/not worked in the past?*
7. Are there any other considerations of which we should be aware prior to contacting you about your appointment?*
- Not applicable
- Need for interpreter
- Medical Concerns
- Upcoming changes
- CAS involvement
- Custody arrangements
- Cultural or religious considerations
- Primary caregiver unable to participate/facilitate sessions
- Other
If considerations were selected, please describe:
Please specify your preferred appointment time:*
- Morning
- Afternoon
- Evening
- Specific date and time
If "Specific date and time" was selected above, please specify:
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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