CHEO School Based Rehabilitation Services (SBRS) Referral Form

Speech-Language Pathology Services

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. 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will be used to arrange necessary services as part of the student's treatment at school, and that this consent can be withdrawn at any time

Speech Language Pathology Services

Articulation and Phonological Difficulties
A1 Subjective Clinical Impression of Severity
Motor Speech Difficulties
A2 Subjective Clinical Impression of Severity
Fluency Difficulties
A3 Subjective Clinical Impression of Severity
Voice/ Resonance Difficulties

Report from ENT or Cleft Palate team required within 6 months of referral

Check if the referral is related to

Report from ENT or Cleft Palate team completed

A4 Subjective Clinical Impression of Severity
Sections B-E are to be completed for ALL referrals
B - Speech Intelligibility
C - Social Impact
D - Emotional Impact
E - Academic Impact
Note: A Speech-Language Pathology report must accompany this referral within 24 hours of submission. The Speech-Language Pathology report must be recent, within the last 12 months. Please fax all applicable reports and supporting documents to 613-738-4853. Referrals not accompanied by an Speech-Language Pathology report will be denied.
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 11:32:12 AM.