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BEHAVIOUR SUPPORT SOLUTIONS

tel 519-575-5387 email: info@behavioursupportsolutions.com

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Intake Form & Consent Form

Please provide the details of the individual you are referring or self referring- please note a more formal detailed intake process will occur after review of details and follow up call has occured. Thank you

First name

Last name

Address*

Phone*

Email*

Date of birth

Year

Month

Day

Parent or Guardian or Substitute Decision Maker Informaton

Service Coordinator or Community Support Agency Contact Information

Check all that apply

Do you attend School?

Do you attend Camps?

Do you participate in a Day program regularly?

Do you participate in respite services ?

Do you actively volunteer or have an employment position?

Do you use Mobility Plus /GRT

Do you have an Acesss2 Card?

Do you have Passport Services?

Do you have SSAH?

Do you have a Independent Support Plan?

Do you have a behavioural support plan?

Do you presently have a case manager or service coordinator?

Do you enjoy exercise and Physical activity?

Do you have Ontario Health at Home Services ?

Do you urgently need services to start today?

If you answered yes to any of the questions above, please supply additional information.

Initials*

I declare that the info I’ve provided is accurate and complete.

Consent to Share and Collect Personal Information I/We herby consent to Name of parent/guardian or client (Please Print) Behaviour Support Solutions (BSS) obtaining Please note a more formal document will be sent for e-signature or physical sign off*

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