Do you want a copy of the referral emailed to you? Yes No Email If you need help to fill this form, please send us an email at admin@dsoer.ca If at any stage in completing this form you find you need more time to gather documentation you can scroll to the bottom and select "Save and Continue Later". We will provide you with a special link that will allow you to finish the form without having to reenter the fields completed. SECTION 1 - TO: DEVELOPMENTAL SERVICES ONTARIO EASTERN REGION.Referred by Agency:* Yes No Agency Name: Contact Name: PhoneEmail SECTION 2 - CONSENTPERSON’S METHOD FOR DECISION-MAKING:*Choose an itemPerson makes his/her own decisionsPerson makes decisions with support of familyPerson has a substitute decision makerSubstitute decision maker First Name Last Name DOES THE PERSON (or his/her Key Contact) CONSENT TO THE REFERRAL TO DSOER? Yes No If YES, please complete the consent form with the person save it to your computer and then upload with the button below. If you wish to take advantage of the digital signature fields you will need to download Adobe Acrobat. This is a free download: Get Acrobat ReaderUpload Consent FormMax. file size: 512 MB.If NO, please further elaborate:SECTION 3 - INFORMATION ABOUT THE PERSON SEEKING SERVICES AND SUPPORTS:Name* First Middle Last Date of Birth* MM slash DD slash YYYY Gender* Female Male Unknown Not disclosed I confirm that the person seeking services and supports is 16 years of age or older:* Yes No Referral can only be submitted for individuals 16 years old or olderAddress* Street Address Unit, Apartment, Suite Number City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Area*Choose OneOttawaRenfrew CountyUnited Counties of Stormont, Dundas & GlengarryUnited Counties of Prescott-RussellMother's Maiden Name* Home PhoneEmail Address Work PhoneCell PhonePreferred Language English French Marital status*Choose OneSingleMarriedWidowedSeparatedDivorcedCommon LawDomestic PartnerInterpreter required Yes No Specify Language SECTION 4 - THE PERSON'S KEY CONTACT:Name First Last Relationship to the person Is the address the same as the person registering above? Yes No Address* Street Address Unit, Apartment, Suite Number City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Area*Choose OneOttawaRenfrew CountyUnited Counties of Stormont, Dundas & GlengarryUnited Counties of Prescott-RussellPreferred contact number or email:PhoneEmail Who to contact ? Person Key Contact Agency SECTION 5 - SERVICES REQUESTEDClick here to access the service definitionsMinistry-funded services and supports for adults with developmental disabilities Service Navigation Residential Support Community Participation Caregiver Respite Person Directed Planning Passport File Update or Re-Assessment (for Adult Developmental Services and Supports) Specialized Services Adult Protective Services Behaviour Management Case Management Counseling Dual Diagnosis Brokerage Service Justice Brokerage Occupational Therapy Speech and Language Therapy Details on File Update or Re-Assessment (for Adult Developmental Services and Supports)Is the service required immediately?* Yes No If yes, indicate all reasons for urgency as listed below The person providing care is unable to continue providing care as of today I have no residence or am at risk of having no residence in the very near future My support needs have changed, my current support arrangement may soon become untenable and my well-being is likely to be at risk In addition to above choice: My formal and informal supports are not available to reduce the risk of harm or address the need. Provide additional details about the urgencySECTION 6 - ELIGIBILITY DOCUMENTSI am uploading a psychological assessment or report signed by a psychologist or psychological associate registered with the College of Psychologists of Ontario (or equivalent body in another province) that states the person has a developmental disability in accordance with the Services and Supports to Promote the Social Inclusion of Persons with Developmental Disabilities Act and Regulation?* Yes No FileMax. file size: 512 MB.I am uploading a document that provides proof of age (document displays the person's name and date of birth)* Yes No FileMax. file size: 512 MB.I am uploading a document that provides proof of Ontario residency (documents displaying the person's name, address and citizenship status)* Yes No FileMax. file size: 512 MB.Click on the following link for more information on the acceptable eligibility documentation General terms: a. Uploaded documents are directed to a confidential email address. b. File will be created as "in progress" I understand the risks of uploading documentation containing personal information, as with all electronic information systems.* Yes, I understand the risks Important: You must complete all the required fields to submit your form. Once done, click on the "Submit" button. (the button appears only when all required fields have been completed)
