Fillable Winnipeg CTI Referral Form March 2016

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Winnipeg CTI Referral Form March 2016

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Country of origin: CANADA
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CENTRAL INTAKE - Referral Form
SSCY Centre
1155 Notre Dame, Winnipeg, MB R3E 3G1
Audiology
Occupational Therapy
Physiotherapy
Speech-Language Pathology
Phone: 204-258-6550 Fax: 204-258-6799
CHILD INFORMATION
LAST NAME
FIRST NAME
BIRTH DATE
M
D
Y
MALE
FEMALE
ADDRESS
CHILDREN’S THERAPY INITIATIVE – WINNIPEG (CTI-WPG) CENTRAL INTAKE PARTNERS
CITY
Postal
Code
CNIB
Central Speech and Hearing Clinic Inc.
Health Sciences Centre
Rehabilitation Centre for Children
Society for Manitobans With Disabilities
St.Amant
St. Boniface Hospital
Winnipeg Regional Health Authority
PHIN#
MHSC#
PRIMARY LANGUAGE
REFERRAL SOURCE
NAME & DESIGNATION
SERVICES PREFERRED
ENGLISH FRENCH
INTERPRETER YES NO
SIGNATURE
PRIMARY DOCTOR
ADDRESS
DOCTOR’S PHONE
PHONE
FAX
DOCTOR’S ADDRESS
HAS THE FAMILY/CAREGIVER BEEN INFORMED ABOUT THIS REFERRAL?
YES NO
PARENT(S) OR GUARDIAN(S) (Please check box to indicate which parent/caregiver this child lives with)
PARENT/CAREGIVER NAME
RELATIONSHIP
PRIMARY PHONE
ALTERNATE PHONE
IF THIS CHILD RESIDES WITH SOMEONE OTHER THAN HIS OR HER LEGAL GUARDIAN, OR IS IN THE CARE OF A CHILD & FAMILY SERVICES AGENCY, THE FOLLOWING SECTION MUST BE COMPLETED
LEGAL GUARDIAN
PHONE
FAX
AGENCY NAME
ADDRESS
POSTAL CODE
REASON FOR REFERRAL (Check all that apply)
AUDIOLOGY FOR CHILDREN AGES 0 TO 17
OCCUPATIONAL THERAPY
PHYSIOTHERAPY
SPEECH-LANGUAGE PATHOLOGY
Auditory Processing Assessment
Child must be 8 years or older.
Second Opinion
(Include background info & previous audio results)
Neonatal Risk Factors for Hearing Loss
___________________________________
Syndrome Associated with Hearing Loss
___________________________________
Parental Concern
Ear Infections
Family History of Childhood Hearing Loss
Speech Delay
No Speech
Failed School Screening
(Provide School Name)
___________________________________
Feeding Concerns, specify:
Adaptive Play Skills
Fine Motor Skills
Attention and Organization
Self-Care Skills
Peer Interactions
Sensory Processing
Delayed Developmental Milestones
Gross Motor Coordination
Balance
Strength
Walking / Running
Plagiocephaly
Torticollis
Delayed Gross Motor Milestones
Musculoskeletal Concerns, Specify:
Difficulty Talking
Difficulty Understanding Information
Difficulty Interacting with Others
Stutters
(3+ Repetitions of Word/Sound)
Difficult to Understand
Delayed Developmental Milestones
COMMENTS (Diagnosis, Presenting Concerns, etc)
Children attending a school in the Winnipeg School
Division are eligible for audiology services from:
Audiology, Winnipeg School Division
1075 Wellington Cr., Winnipeg, MB
Fax directly to: 204-783-1149
Approved(12/08/2015(
DATE RECEIVED
INTAKE USE ONLY
INTAKE INFORMATION
THIS REFERRAL WILL BE DIRECTED TO THE MOST APPROPRIATE SERVICE PROVIDER AND / OR TO THE CHILD’S HOME REGION
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Winnipeg CTI Referral Form March 2016

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Completed 11 March 2022

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