URS Referral Form

In Algoma, Nipissing, Parry Sound & Muskoka, children and youth up to age of 18, registered with the Ontario Autism Program (OAP), can be referred for Urgent Response Services (URS) through the Children’s Community Network.

URS is a time limited rapid response service intended to address a specific behaviour need with a focus on preventing further escalation of risk of harm.

Who is Eligible for URS

Children/youth exhibiting the following high-risk behaviours, that have started or escalated in intensity over the last 14-days:

• Suicidal Ideation or Behaviour • Violent Thinking
• Fire Starting • Harm to Animals
• Risk of Exploitation • Self-Injurious Behaviour
• Aggression • Inappropriate Sexual Behaviour
• Flight Risk • Property Destruction

*Please note that additional screening will be completed by the Urgent Response Services Coordinator to determine eligibility for this program.

Step 1 of 2 - Child/Youth Information

Child/Youth Information

Name(Required)

First Last

Preferred Name

Date of Birth (MM/DD/YYYY)(Required)

Gender

Primary Caregiver Name(s) (Legal Guardian)(Required)

Relationship to Child/Youth

Address(Required)

Street Address Address Line 2 City Province Postal Code

Primary Phone #(Required)

Alternate Phone #

Email Address

Preferred Language of Service(Required)

Please Specify(Required)

School (If Applicable)

Indigenous Status(Required)

Please Specify(Required)

Clinical Diagnosis(Required)

Diagnosis Source

Date of Diagnosis (MM/DD/YYYY)

OAP Number(Required)

URS Referral Form

Child/Youth Information

Referral Details