Referrals

Our staff will answer your questions to see if we can help.

You can also complete one our referral forms and drop it off at our Centre. Please click on the links below:

Referral for Children’s Treatment Centre of Chatham-Kent

• Referral Form (English)
• Formulaire de référence

School Based Rehabilitation Services:

• School Based Rehabilitation / Central Auditory Processing Services Principal Referral Form (English)
• Services de réadaptation en milieu scolaire Formulaire de recommandation de la direction d’école

Please attach the appropriate checklist to the service you are requesting from below, and attach to the Principal Referral Form completed from above:

Occupational Therapy Checklist

• Occupational Therapy Teacher Checklist – Please print off document complete and forward to the CTC-CK.

Physiotherapy Therapy Checklist

• Physiotherapy Teacher Checklist – Please print off document complete and forward to the CTC-CK.

Speech Therapy Checklist

• SLP Referral Form

Central Auditory Processing

• Auditory Processing Domains Questionnaire (APDQ) completed by teacher – Please print off document complete and forward to the CTC-CK.
• CAPD Teacher Checklist
• Traitement auditif central – Liste de vérification du personnel enseignant

Coordinated Service Planning (CSP)

Referral from community service provider: English Form

Formulaire d’Aiguillage Vers la Planification Coordonnees des Services de Chatham-Kent: French Form

Augmentative Communication Services (ACS) Clinic

Please read the Augmentative Communication  Services (ACS) Information on Services and Referral Services (Part 1) for more detailed information.  The following forms must be completed:

• • • (Part 2) – Request for Augmentative Communication Services (ACS) Clinic Referral Form
    • Augmentative Communication Service Consult Request – French
    • (Part 3) – Augmentative Communication Services (ACS) Guided Assessment-Daily Communication Partners Form (Must be completed and included with referral)
      • Part 3 – Click here for PDF Verison
  • How to request an ACS Consultation? If you have questions about your child’s or student’s communication skills and are not sure about possible next steps, the ACS Clinic offers consultation sessions.  A consultation session can help answer general questions about augmentative communication or focus on a specific child or student.Augmentative Communication Service Consult Request – Document PDF (Click Here)Please complete the Augmentative Communication Service Consult Request form and FAX, mail or email the form to mball@nullCTC-CK.com.For more information on the referral process please contact the Children’s Treatment Centre of Chatham Kent 519-354-0520

Fetal Alcohol Spectrum Disorder Program (FASD)

Referral from community service provider:  English Form

Purchased Services

• • Purchased Services Information
    If you are interested in finding out more about Purchased Services for Occupational Therapy and Speech/Language Therapy, please call Marnie Ball, 519-354-0520, ext. 243.