MyChart -

Please ensure you submit this form in one sitting that is less than 30mins, are using an up-to-date web browser (not Internet Explorer), and have no other MyChart sessions open. If you do not see this a confirmation of submission (“Your Request has been submitted”), the submission was unsuccessful. Please close the web browser window and resubmit.

The personal data collected on the on-line Coordinated Service Planning (CSP) Referral Form is used to verify our current client records and to determine eligibility for admission.

Once the form is received, the Access Team will follow up to complete a needs assessment and determine eligibility for Coordinated Service Planning. This form will be part of the child or youth's medical record, and is confidential.

Please note: If you are submitting this referral on behalf of a family, child or youth please ensure the family is aware and consents to the referral. Consent will be reviewed with family at time of intake.

Please complete one form per child.

Referral Source

Name (Referring Individual)

Agency/Organization (if you are a service provider)

Telephone Number

Child/Youth Information

Last Name

Fist Name

Date of Birth (dd/mm/yyyy)

Address

Address line 2

City

Postal Code

Parent/Guardian Name (first contact)

Relationship

Telephone Number

Legal Guardian

YesNo

Parent/Guardian Name (second contact)

Relationship

Telephone Number

Legal Guardian

YesNo

Language(s) spoken

Preferred Language

Why is Coordinated Service Planning (CSP) being requested

To support coordination of careTo support the connection of the client/family to appropriate services following multiple failed attemptsTo support the client/family in clarifying the roles and responsibilities of care team members and/or systems of careOther

If yes to any of the above, please provide more details to why Coordinated Service Planning is being requested

Additional details line 2

Coordinated Service Planning Referral Form