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FASD - Intervention / Support Request Form

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Child/Youth/Adult Information

Name of the person who is being referred

Sex

Female

Male

Address (if different from the legal guardian)

Town / City

Postal Code

Telephone

Date of Birth

Medicare #

Expiration date

Legal guardian information

Name of legal guardian (if applicable)

Relationship to the referred person

Address

Town/City

Postal Code

Telephone/Contact #’s

Cellular

Preferred language

French

English

Other

Has your child been diagnosed with FASD?

Yes

If yes, by whom?

Did he/she receive a list of recommendations with the FASD diagnosis?

Yes

If yes, could you please provide a copy with this request form?

Does your child have other diagnoses and/or significant medical issues?

Has your child been assessed by… (please include name and date of assessments)

Psychologist

Occupational Therapist

Speech and Language Pathologist

What type of services/ support/ education are you requesting at this time?

Are there supports in place for your child at school?

Are there supports in place for your child outside of school? E.g.: Community agencies, financial, etc.

What is your Child’s current living situation?

Please list your child’s strengths:

Please list your child’s challenges

In order for us to better serve you and your child, please answer the following question

Behavior or learning difficulties

	Yes	No
Acts too young for his or her age?	Acts too young for his or her age? - Yes	Acts too young for his or her age? - No
Cannot concentrate / poor attention	Cannot concentrate / poor attention - Yes	Cannot concentrate / poor attention - No
Cannot follow directions or rules at home or at school	Cannot follow directions or rules at home or at school - Yes	Cannot follow directions or rules at home or at school - No
No guilt after misbehavng	No guilt after misbehavng - Yes	No guilt after misbehavng - No
Impulsive / acts without thinking	Impulsive / acts without thinking - Yes	Impulsive / acts without thinking - No
Lying at home and outside the home	Lying at home and outside the home - Yes	Lying at home and outside the home - No
Lack of focus	Lack of focus - Yes	Lack of focus - No
Organizational difficulties	Organizational difficulties - Yes	Organizational difficulties - No
Difficulty with task initiation	Difficulty with task initiation - Yes	Difficulty with task initiation - No
Difficulty with transition	Difficulty with transition - Yes	Difficulty with transition - No
Speech and language difficulties	Speech and language difficulties - Yes	Speech and language difficulties - No
Learning difficulties	Learning difficulties - Yes	Learning difficulties - No
Sleep difficulties	Sleep difficulties - Yes	Sleep difficulties - No
Difficulty with coordination / motor skills	Difficulty with coordination / motor skills - Yes	Difficulty with coordination / motor skills - No
Poor social skills	Poor social skills - Yes	Poor social skills - No