Laurel Behaviour Support Services

Request For Service Application Form

Please fill out the online form with as much information as possible. Once you submit the form, our Behaviour Support Services Coordinator will be in contact with you shortly.

Name:
Relation to Child:
Home Phone:
Cell Phone:
Email Address:
Child Information
Name:
Date of Birth:
Gender:	Male Female
Address:
What is the specific diagnosis?
When was the diagnosis?
Please describe your son or daughter. Identify strengths and areas of growth.
What is your primary reason for contacting us?
Are there any other services being received? Speech, OT, etc.
Is the child in daycare or school?
If in daycare or school, during what periods?
Would a consultant be permitted in the school or daycare?
Have BI's been hired?
What are the parents schedules?
Please specify:	Early Intervention (EIBI) (Children aged 0-6 years) General Behaviour Support Services (Children over 6 years)
Have you contacted MCFD?	Yes No
Is Autism Funding in place?	Yes No
Were you referred?	Yes No
If you were referred, by whom?

	Thanks for filling out this information form. Please click the submit button and your information will be sent securely to our Behaviour Support Services Coordinator. Please be assured that your information is kept confidential and will never be shared with anyone.