CHEO School Based Rehabilitation Services (SBRS) Referral Form

Occupational Therapy/ Physiotherapy

Fax: 613-738-4853

Phone: 613-737-7600 ext. 6256

Please note that School and School Board resources and supports available to the student must be accessed prior to making a referral to School Based Rehabilitation Services (SBRS). For additional information about the SBRS program, please visit School-based Rehabilitation Services - CHEO

All fields marked with a * are required.

Student Information
Parent/ Guardian Contact Information (1)
Address
Please select your preferred phone number
Language
Interpreter required?

By providing the parent/guardian email, they are aware that it authorizes CHEO to communicate with them via email about the SBRS program. Email will not be used for urgent or sensitive communication

Parent/ Guardian Contact Information (2)
Address
Please select your preferred phone number
Language
Interpreter required?

By providing the parent/guardian email, they are aware that it authorizes CHEO to communicate with them via email about the SBRS program. Email will not be used for urgent or sensitive communication

School Information
School
Class Placement
Primary school contact
The school is required to be actively involved in supporting the student while they are in the SBRS program as OT/PT services operate on a consultative model. Therapists will provide recommendations for the school to implement. Please check off who will be the most responsible individual/ primary school contact for the therapist and provide their name.
Please select one of the following
Secondary school contact (optional)
Please select one of the following
Attestation

If the referral is for a student in Grade 7 or above: The Referral Source attests that they have spoken to the student who is being referred, and the student is agreeable to the SBRS referral and will be receptive to the recommendations

Please select one of the following
Consent

I, the referral source, have obtained student/parental/legal guardian consent to complete this referral for CHEO's SBRS program. I have reviewed with the student/parent/legal guardian that the information collected, used, and disclosed will be used to arrange necessary services as part of the student's treatment at school, and that this consent can be withdrawn at any time

Consultation Requested
Please select

Reason for Consultation

Please describe any concerns you have about the student's ability to participate in school

Safety and Accessibility
Do the referral concerns affect the student's ability to attend school?
Please check those that apply

Is there a safety issue?
These documents are confidential and are for the sole use of the intended recipient. Any unauthorized use, disclosure or distribution is prohibited. All SickKids lab results contained in this medical record were generated by a clinically accredited laboratory. The laboratory is not a forensically accredited laboratory. Testing by the laboratory is carried out for clinical use and results are not intended for forensic use. If you mistakenly receive these documents please destroy and contact the sender immediately. This page was printed on Thursday 05 December 2024 at 12:11:28 PM.