Online Application

Please indicate which weeks

NoneFor health concernFor epilepsy/seizuresFor mood, anxiety, sleep or behaviourOther (please specify)

Walks without aidsWalks with aidsUtilizes a wheelchair independentlyUses a wheelchair with assistance (e.g. staff will be required to assist them)

VerbalVocalizes/makes soundsPEC SymbolsASL or modified signNon-verbal (please specify)

Independent completely*

YESNO

Can be left alone for short periods of time*

YESNO

Requires constant supervision*

YESNO

Requires prompts/reminders*

YESNO

Will wander*

YESNO

Able to follow verbal instructions*

YESNO

Needs hand over hand assistance for manual tasks*

YESNO

Toilets themselves independently*

YESNO

Needs assistance with personal care/toileting*

YESNO

Able to wash hands*

YESNO

Able to feed themselves*

YESNO

Able to dress themselves*

YESNO

Needs assistance with shoes, boots or outerwear*

YESNO

Can write own name*

YESNO

Can write words*

YESNO

Able to read*

YESNO

Can identify letters*

YESNO

Can identify numbers*

YESNO

Understands money*

YESNO

Sensitive to loud noises.*

YESNO

Requires a lot of personal space (arms length or more)*

YESNO

Sensitive to the heat/sun*

YESNO

Sensitive to the cold/winter*

YESNO

ASSESSMENTS COMPLETED BY THE DSO

Please attach a copy of any assessments you have access to from the DSO, including but not limited to the Support Intensity Scale (SIS) and The Application for Developmental Services and Supports (ADSS).

Submit an online application below and we will get back to you shortly!

Please indicate which Program you are applying for:*

Please indicate which weeks

APPLICANT INFORMATION

Date of birth

Gender*

PARENT / PRIMARY CAREGIVER INFORMATION

Phone

Best way to contact you:*

PRESENT LIVING ARRANGEMENTS*

PAST DAY ACTIVITIES

FORMAL DIAGNOSIS AND MEDICAL CONDITIONS

CURRENT MEDICATIONS*

Will medication need to be administered during the 8:30am – 3:30pm day?*

ALLERGIES AND FOOD SENSITIVITIES

Is an auto-injector required?*

MOBILITY*

FORM OF COMMUNCTION*

LEVEL OF INDEPENDENCE

SELF CARE

LITERACY SKILLS

ENVIRONMENTAL FACTORS

BEHAVIOURAL CHALLENGES

PERSONAL INTERESTS

COMMENTS

ASSESSMENTS COMPLETED BY THE DSO

Forms Attached*

HOW DID YOU HEAR ABOUT US?*

DAYS OF THE WEEK REQUIRED*

SIGNATURE

Knowledge Makes
All the Difference

Your Family Is
in Good Hands

We Help You Choose a Better Heath Care Facility

Request a Call Back

Online Application

Submit an online application below and we will get back to you shortly!

Please indicate which Program you are applying for:*

Please indicate which weeks

APPLICANT INFORMATION

Date of birth

Gender*

PARENT / PRIMARY CAREGIVER INFORMATION

Phone

Best way to contact you:*

PRESENT LIVING ARRANGEMENTS*

PAST DAY ACTIVITIES

FORMAL DIAGNOSIS AND MEDICAL CONDITIONS

CURRENT MEDICATIONS*

Will medication need to be administered during the 8:30am – 3:30pm day?*

ALLERGIES AND FOOD SENSITIVITIES

Is an auto-injector required?*

MOBILITY*

FORM OF COMMUNCTION*

LEVEL OF INDEPENDENCE

SELF CARE

LITERACY SKILLS

ENVIRONMENTAL FACTORS

BEHAVIOURAL CHALLENGES

PERSONAL INTERESTS

COMMENTS

ASSESSMENTS COMPLETED BY THE DSO

Forms Attached*

HOW DID YOU HEAR ABOUT US?*

DAYS OF THE WEEK REQUIRED*

SIGNATURE

Knowledge Makes All the Difference

Your Family Is in Good Hands

We Help You Choose a Better Heath Care Facility

Request a Call Back

Knowledge Makes
All the Difference

Your Family Is
in Good Hands