Children’s Services – Request For Services Male Female

Child’s Last Name: Child’s First Name: Date of Birth: Physician: Parent Guardian: Home Phone: Mom Daytime Contact #: Dad Daytime Contact #: Address: School: School Address: School Phone #: Teacher: SERT/SST/LRT: Grade Reason(s) for Referral / Services Requested: Allergies:

____, ____, ______Signature: Title: Date: DD MM YYYY

RELEASE OF INFORMATION AND CONSENT TO ASSESSMENT:

I do hereby give consent to the school named above to release/share information, including third party reports, relevant to the care and status of my child ( (student’s name) to Home and Community Care Support Services South East as deemed necessary for the consideration of School Health Support Services.

STUDENT’S HEALTH CARD #: Version Code: EXPIRY DATE: _

PARENT/GUARDIAN SIGNATURE: DATE:

RELATIONSHIP TO STUDENT: CHILDREN’S SERVICES REQUEST FOR SERVICES STANDARDS FOR COMPLETION

Top portion of the form is to be completed by school personnel. Complete all sections and ensure there is an explanation as to why a specific service is being requested from Home and Community Care Support Services South East A parent or guardian must complete and sign the bottom portion of the form titled “Release of Information and Consent to Assessment”. Health Card Information is required and is part of the eligibility requirements for school support services throughout Home and Community Care Support Services South East.

Home and Community Support Services South East Locations:

Kingston Phone: 613-544-7090 Fax: 613-544-1494 1471 John Counter Blvd., Suite 200, Kingston, , K7M 8S8

Belleville and Picton Fax: 613-966-0996 Phone: 613-966-3530 470 Dundas Street East, Belleville, Ontario, K8N 1G1

Bancroft Fax: 613-332-4873 Phone: 613-332-2444 1 Manor Lane, Bancroft, Ontario, K0L 1C0

Brockville Fax: 613-283-0308 Phone: 613-283-8012 555 California Ave, , Ontario, K6V 7K6

Smiths Falls Fax: 613-283-0308 Phone: 613-283-8012 52 Abbott Street North, Unit 1, , Ontario, K7A 1W3

March 2014/LM – March 2021/HF

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