WRHA AUDIOLOGY REFERRAL PROCESS 1. Fax Your Referral (837-5781) to Audiology Central Intake

INTAKE USE REQUIRED INFORMATION ONLY

REFERRAL AUDIOLOGY REFERRAL DATE MA L E  COMMUNICATION DISORDERS - GRACE HOSPITAL F E M A L E  300 Booth Drive Winnipeg, Manitoba R3J 3M7 LAST NAME a

Phone 837-0511 Fax 837-5781 FIRST NAME BIRTH DATE D M Y

AUDIOLOGY ASSESSMENT  ADDRESS REQUEST (Include background information & previous audio results) 2ND CITY PC FOR: OPINION  ABR  PARENTS

AUDITORY PROCESSING ASSESSMENT  HOME PHONE CELL (Children must be 8 years or over. Assessments by SLP and Psychology required - Please Advise Parents) WORK PHONE

Referr MHSC# PHIN# al ADDITIONAL INFORMATION IF APPLICABLE Sourc e HOSPITAL#

Addre PHYSICIAN ss CFS WORKER

ADDRESS

PC PHONE FAX

Has this client had a previous test?  Yes  No Where? ______(Client may call site directly for a follow-up appt) Date ______

SERVICES FOR CHILDREN SERVICES FOR ADULTS

CHILDREN ATTENDING PUBLIC SCHOOL IN THE WPG SCHOOL DIVISION (Schools in the postal REASONS FOR REFERRAL: (Check all that code areas R2R R2W R2X R3A R3B R3C R3E R3G R3L R3N R3M) are eligible for audiology services through apply) Child Guidance Clinic. Please check with parents and refer directly to:  Sudden Onset Hearing Loss Date Child Guidance Clinic - Fax: 783-6068 ______

SCHOOL CHILD ATTENDS ______ Unilateral Hearing Loss  Rule out retrocochlear pathology POTENTIAL RISK FACTORS  Head or ear trauma  Craniofacial anomalies  Intrauterine Growth  NICU > 48 hours  Syndrome associated with Restriction  Ototoxic medications/monitoring  Birth weight < 1500 hearing loss  Maternal Substance Abuse  Pre-operative assessment grams (associated with craniofacial ______Date ______ Parental Concern anomalies or growth < Surgery Type ______ Apgar < 4 at 5 10%ile) minutes  Post-operative assessment Date ______RISKS FOR PROGRESSIVE OR DELAYED Surgery Type ______HEARING LOSS  Neurodegenerative Disorder  Hearing loss questioned  Persistent Pulmonary Hypertension of the ______ At risk due to noise exposure Newborn (PPHN)  Hypoxic-Ischemic Encephalopathy (HIE)  Hyperbilirubinemia > 400 µmol/L OR  Birth weight < 1250 grams  To initiate a WCB or VAC (DVA) claim exchange transfusion  Intraventricular Hemorrhage (Grade III or IV)  Tinnitus  Unilateral  Bilateral  Prolonged Mechanical Ventilation > 5 days  Periventricular Leukomalacia  Audiogram required for a medical  ECMO or iNO or HFO or HFJ ventilation  Ototoxic medications (Gentamicin pre-dose  STORCH level > 2.5 mg/L; Lasix and gentamicin  Vestibular Concerns  Family history of childhood hearing loss combined > 5 days, Vancomicin pre-dose  Hearing aid concerns  Congenital Diaphragmatic Hernia level >10 mg/L) COMMENTS  Syndrome associated with progressive  Meningitis ______hearing loss ______CHECK OTHER CONCERNS: CHILD HAS BEEN REFERRED FOR SPEECH ______ Hearing Loss Questioned   Unable to follow simple directions  No speech  No response to loud sounds  Speech or Language Delay ACCESS RIVER EAST WRHA AUDIOLOGY REFERRAL PROCESS Audiology 975 Henderson Hwy 1. Fax your referral (837-5781) to Audiology Central Intake at the Grace Hospital. Winnipeg, Manitoba R2K 4L7 2. Urgent referrals are distributed immediately. Clients are notified by telephone or by mail with instructions on how to schedule the appointment. Please note that we are unable to schedule appointments at Central Intake.

3. Less urgent referrals are placed on the central wait list. Clients are notified by mail that the referral has been placed on a wait list. Referrals are taken off the wait list in order of priority and date referred. DEER LODGE HEARING CENTRE 4. Clients, who have previously had their hearing tested at one of the sites listed on the left, can call Deer Lodge Centre directly to schedule their follow-up appointment. If they are unsure where they were seen, they can 2109 Portage Avenue call 837-0511 for further information. Winnipeg, Manitoba R3J 0L3 5. Referrals for clients who attend public school in the Winnipeg School Division are eligible for services through Child Guidance Clinic who will provide audiology services at the school the child attends. Please refer directly to:

Child Guidance Clinic 2nd Floor, 700 Elgin Avenue The Winnipeg School Division includes schools in the postal code areas of: Winnipeg, Manitoba R3E 1B2 R2R R2W R2X R3A R3B R3C R3E R3G R3L R3N R3M HEALTH SCIENCES CENTRE Fax: 783-6068 General Hospital, Audiology Children’s Hospital, Audiology 6. Referrals for clients living outside of Winnipeg can be sent directly to: 820 Sherbrook Street Winnipeg, Manitoba Brandon Regional Health Authority Norman Regional Hearing Centre - Children R3A 1R9 - Audiology Primary Health Care Centre Unit A5 – 800 Rosser Avenue 111 Cook Avenue, Box 240 Brandon, Manitoba R7A 6N5 The Pas, Manitoba R9A 1K4 Phone: 1 204 571-8366 Phone: 1 204 623-9697 Fax: 1 204 627-8285 Fax: 1 204 726-8743

Burntwood Regional Hearing Centre North Eastman Health Assoc. Inc., SEVEN OAKS HEARING CENTRE 867 Thompson Drive South Audiology Seven Oaks General Hospital Thompson, Manitoba R8N 1Z4 Beausejour Primary Health Care Centre 2300 McPhillips Street Phone: 1 204 677-5385 P.O. Box 550, 151 First Street S. Winnipeg, Manitoba Fax: 1 204 778-1453 Beausejour, Manitoba R0E 0C0 R2V 3M3 Phone: 1 204 268-7489 Fax: 1 204 268-4399

Central Regional Hearing – Adults Parkland Regional Therapy Services - 25 Tupper Street North Children Portage La Prairie, Manitoba R1N Central Intake – Children’s Therapy Initiative 3K1 Dauphin Regional Health Centre Phone: 1 204 239-3117 625 3rd Street S.W. ST. BONIFACE GENERAL HOSPITAL Fax: 1 204 239-3148 Dauphin, Manitoba R7N 1R7 Audiology Phone: 204 638-2164 Fax: 204 638-2228 409 Tache Avenue Winnipeg, Manitoba Central Regional Rehab Services - South Eastman Health – Audiology R2H 2A6 Children P.O. Box 2560, 365 Reimer Avenue Box 2000 Station Main Steinbach, Manitoba R5G 1P1 Winkler, Manitoba R6W 1H8 Phone: 1 204 346-7009 Fax: 1 204 346-7023 Phone: 1 204 331-8833 Fax: 1 204 331-8913 Toll Free: 1 800 958-3076

VICTORIA HEARING CENTRE Interlake Regional Hearing Centre Victoria General Hospital c/o Selkirk & District General Hospital 2340 Pembina Hwy. PO Box 5000, 100 Easton Drive Winnipeg, Manitoba Selkirk, Manitoba R1A 2M2 R3T 2E8 Phone: 1 204 785-7497 Fax: 1-204- 785-9113

7. The referral source will be notified if,

. Clients do not attend their scheduled appointment. . Clients decline an appointment. . We are unable to contact the client by mail or phone. Referral forms available by mail/email (Word format) Call 837-0511